Download August 28, 2003 - Southern Center for Human Rights

EXPERT REPORT OF STEPHEN TABET, M.D., MPH
Leatherwood v. Campbell
Case No. CV-02-BE-2812-W
In The United States District Court
Northern District of Alabama
Western Division
Dated: August 26, 2003
TABLE OF CONTENTS
TAB
A.
QUALIFICATIONS
PAGES
4-5
B.
BASIC SCIENCE OF HIV
6-7
C.
STANDARDS OF CARE
8
D.
FACILITY TOUR AND OBSERVATIONS
PHOTOGRAHS 1 AND 2
9-10
E.
PATIENT EXAMINATIONS
1. PATIENT 1 (PHOTOGRAPH 3)
2. PATIENT 2 (PHOTOGRAPH 4)
3. PATIENT 3
4. PATIENT 4
5. PATIENT 5 (PHOTOGRAPHS 5 AND 6)
6. PATIENT 6
7. PATIENT 7
8. PATIENT 8
9. PATIENT 9
10. PATIENT 10
11. PATIENT 11
12. PATIENT 12 (PHOTOGRAPH 7)
13. PATIENT 13 (PHOTOGRAPHS 8 AND 9)
14. PATIENT 14
15. PATIENT 15
16. PATIENT 16 (PHOTOGRAPH 10)
17. PATIENT 17
18. PATIENT 18
19. PATIENT 19 (PHOTOGRAPHS 11 AND 12)
11
12
13
14-15
16-17
18
19
20
21
22
23
24
25
26
27
28
29
30-31
32
33
F.
MORTALITY REVIEWS
1. RUSSELL BATTISTE
2. LUIS BLANCO
3. JOHN BOLTON
4. ANTHONY COX
5. ANDY CRAWFORD
6. EZELLE DANIELS
7. LARRY DAVENPORT
8. HOWARD DAVIS
9. ANDREA EDWARDS
10. MICHAEL ELLIOT
11. TERRELL GREY
34
35-36
37-38
39-40
41-43
44
45-47
48-49
50-51
52-53
54-55
56-58
2
12. CHELSEA HAMMAC
13. EDDIE HARRIS
14. KELVIN HARRIS
15. MICHAEL HEADON
16. DENNIS HEARNS
17. CLETIS JOHNSON
18. LESLIE JOHNSON
19. MORRIS JOHNSON
20. STANLEY LILLIE
21. WILFORD LOCKETT
22. JOSEPH McCLURE
23. GEORGE McHEARD
24. JAMES PRYOR
25. WILLIE ROBINSON
26. TONY ROWLAND
27. DIONICIO SALAZAR
28. MILTON SMILEY
29. LAMAR SMITH
30. TIMOTHY SUMMERS
31. RICKEY THOMPSON
32. HENRY TURNER
33. FREDDIE WHITE
34. DEWAYNE WILDER
35. IVERSON WILLIAMS
36. JOHN WILLIS
37. EARNEST WYNN
38. MARVIN YOUNGBLOOD
59
60
61-62
63-64
65-66
67-68
69-70
71-72
73-75
76-77
78-79
80
81
82-83
84-85
86-87
88-89
90-91
92-94
95-96
97-98
99-100
101-102
103-104
105-106
107-108
109-110
G.
SUMMARY
111-113
H.
RECOMMENDATIONS
114-116
ATTACHMENTS
I.
CIRRICULUM VITAE
117-124
3
QUALIFICATIONS
Stephen Tabet, MD, MPH
See my attached abbreviated Curriculum Vitae for additional information regarding my
training and qualifications to serve as an expert witness and provide expert commentary
on this case.
In 1991, I received my Doctorate in Medicine (M.D.) with high honors (Junior Year
Alpha Omega Alpha National Honor Society) from the University of New Mexico
(UNM). My doctoral dissertation focused on assessing health care workers’ attitudes
and fears regarding HIV-infected patients. While in medical school, I started providing
medical care for HIV-infected patients at the UNM Hospital AIDS Clinic. During
medical school, I undertook independent research projects in the area of HIV/AIDS
including a study assessing HIV and hepatitis among street-based prostitutes, presented
at the World AIDS Conference and published articles in peer-reviewed journals. I have
since published dozens of articles, manuscripts, and abstracts and have presented
literally several hundred lectures in the area of HIV/AIDS.
In 1993, I completed my Master of Public Health (MPH) in epidemiology at the
University of Washington (UW) School of Public Health and undertook residency
training in Preventive Medicine. For my Master’s thesis, we were one of the first
groups in the world to develop and use molecular epidemiologic methods to track and
prevent the spread of tuberculosis among HIV-infected persons. My research resulted
in the publication of manuscripts in peer-reviewed medical journals and presentations at
national and international medical conferences. I then helped lead public health efforts
to decrease the transmission of tuberculosis among HIV-positive persons in Seattle.
In 1994, I completed internship and residency at the UW School of Medicine
specializing in Internal Medicine. I went on to further sub-specialize in Infectious
Diseases with a concentration in HIV/AIDS at the UW from 1994-97. Upon
completion of my Infectious Disease fellowship, I was recruited to become a faculty
member at the UW where I am currently Assistant Professor of Medicine in the
division of Infectious Diseases. I am double Board Certified in Internal Medicine and
Infectious Diseases. I am also Attending Physician in Internal Medicine and Infectious
Diseases at the public hospital - Harborview Medical Center (HMC) – in Seattle. One
of my main responsibilities at HMC is to provide medical care to patients at Madison
AIDS Clinic where we follow over 1200 HIV-infected patients. The majority of these
HIV-infected patients suffer from drug and/or alcohol addiction and almost all are
homeless, uninsured, mentally ill, or were recently incarcerated. I also serve as one of
the main HIV consultants in the community for particularly challenging patients. I
teach clinical HIV to medical students, residents, post-doctoral fellows, and practicing
physicians. I do a substantial amount of research in the area of HIV/AIDS prevention
and treatment both locally and internationally and have been a co-investigator on
several National Institutes of Health-funded research grants – the most recent of which
is a grant to assess antiretroviral treatment regimens for patients in Lima, Peru – where
access to these medications is virtually non-existent. I truly understand the barriers that
4
exist in providing medical care to HIV-infected patients in resource-poor settings both
in the U.S. and abroad.
I hold numerous local and national appointments. I was appointed by former President
Clinton and Secretary Shalala to serve as a member of the Department of Health and
Human Service’s Health Resources and Service Administration’s HIV/AIDS Bureau
Advisory Committee; the HIV/AIDS Bureau is the largest single provider of care to
persons living with AIDS in the US and provides HIV services to the vast majority of
our nation’s underserved HIV-infected patients. I am currently a member of the
CDC/HRSA Advisory Committee on HIV and STD Prevention and Treatment and
advise the current administration on these concerns. I also serve as Senior Advisor to
Brown University’s HIV Education Prison Project, the largest HIV education program
for correctional providers in the U.S.
I have over 7 years providing care to incarcerated HIV-infected patients and working in
correctional facilities throughout the State of Washington. I lead a group of physicians
that has provided medical care to several thousand incarcerated patients. I have worked
in prison settings where we were under federal court decrees because of medical
problems that occurred in the past. I am Director of the Northwest Correctional
Medicine Education Project where I teach other physicians and providers HIV
medicine. As part of this project, I operate an electronic mail consultation service and
newsletter. This service is provided free of charge to over 450 providers caring for
incarcerated patients. I lecture widely both regionally and nationally on the subject.
5
BASIC SCIENCE OF HIV
Stephen Tabet, MD, MPH
Basic Science of HIV
It is important to first briefly describe the biology of HIV disease and to define terms I will
be using in order to make this report more understandable to the reader. There are literally
tens of thousands of medical articles published each year on the subject of HIV/AIDS. It
has been said that to understand AIDS is to understand all of medicine.
AIDS and HIV
The Acquired Immune Deficiency Syndrome (AIDS) is the end-result of usually long-term
infection with the Human Immunodeficiency Virus (HIV). In 1981, the New England
Journal of Medicine published the first articles describing young men with devastating
diseases only previously seen in patients with severely suppressed immune systems. Few
people were to realize that these men had a disease (eventually termed AIDS) that was
already circulating in many parts of the world and that, by year 2001, was to infect 60
million human beings and be the cause of so much suffering and death throughout the
world. Only three short years later, in 1984, a virus, later to be called HIV, was found to be
the cause of AIDS. What really sets HIV apart from the many viruses that cause illness in
humans is that HIV targets and destroys CD4 lymphocytes (or T-cells), a type of white
blood cell that is at the center of the immune system. Without T-cells, the immune system
defenses cannot work properly thus allowing a number of infectious diseases and cancers to
take over the body.
The immune system and T-cells
The immune system is remarkable in that it works intricately to ward off foreign invaders if
there is no disruption in this system. The average healthy persons has about 800-1,000 Tcells, but this number is variable. When a person first becomes infected with HIV the Tcells can drop dramatically, but then increase to an average of about 600, but again, as in
all of medicine, this is variable. In untreated HIV infection, T-cells decrease by an average
of 50 cells per year. Persons with HIV infection and higher T-cells are initially at higher
risk for skin infections such as rashes, boils/abscesses caused by bacteria, or herpes
infection than persons with normal immune systems. HIV-infected persons with low Tcells are also at risk for these same diseases, but the clinical manifestations are often more
severe. It is not until T-cells drop below 200 or even 100 that most clinical illnesses
associated with HIV occur.
Opportunistic Infections and other illness affecting HIV-infected patients
Opportunistic infections (OIs) denote infections capable of causing disease only in a person
whose immune defenses is lowered. The majority of diseases that affect patients with
AIDS are “opportunistic”. For instance, pneumocystis carinii (PCP) is an organism that
can cause a deadly pneumonia in HIV-infected patients, but is harmless to persons with
normal immune systems. Some diseases, such as tuberculosis, can manifest in both HIVinfected persons and persons with normal immune systems, but affect HIV-infected
persons much more commonly and much more severely and are also sometimes termed
“opportunistic”. Persons with HIV infection are also at risk for getting cancers, especially
cancers caused by viruses, such as Kaposi’s sarcoma and cervical cancer.
6
Treatment and combination therapy
In 1995, the number of persons dying from HIV/AIDS dropped precipitously in the
developed world because of the advent of combination antiretroviral therapy (also called
“the cocktails” or highly active antiretroviral therapy – HAART). Prior to that time,
antiretroviral medications were typically being used one drug at a time which disrupted
HIV’s life cycle, but then eventually failed because HIV became resistant to the single drug
and began replicating again. Currently, a minimum of 3 drugs (and sometimes more) in
combination are needed to interrupt life cycle of HIV and the virus becomes “undetectable”
(undetectable viral load). Thus, the goal of antiretroviral combination therapy is to
suppress viral replication to “undetectable” levels and stop the destruction of T-cells.
Because HIV replicates rapidly (billions of time each day), antiretroviral medications must
be taken by the patient appropriately and continuously or HIV becomes resistant to the
medications, they stop working, and the virus in the blood (or viral load) rebounds and Tcells decrease setting up the patient to contract Opportunistic Infections or other HIVassociated illnesses. Prisons, in particular, have been found to be ideal settings to
administer patient’s combination therapy. Studies conducted by Dr. Margaret Fischl in
Florida and others have clearly shown that nearly 100% compliance can be achieved when
treating incarcerated patients.
Years before combination therapy, the use of preventive antibiotics to prevent some
infections became the standard of care of therapy when T-cells decreased below certain
levels. Preventive antibiotics, with combination therapy, are still the mainstay of therapy.
Because these antibiotics are so effective, inexpensive and cost-effective, even many very
poor counties in the world have for many years provided these life-saving medications to
patients. For example, PCP is nearly 100% preventable when a patient takes one antibiotic
once per day. Preventive antibiotics are only a temporizing measure and don’t prevent all
disease so combination antiretroviral therapy must also be used to decrease the replication
of HIV and increase T-cells.
7
STANDARDS OF CARE
This report draws upon the minimal standards of care utilized in order to adequately care
for HIV-infected individuals. These standards include:
The US Department of Health and Human Services and Kaiser Foundation, the Infectious
Disease Society of America (IDSA), the Center for Disease Control and Prevention (CDC),
and the National Commission on Correctional Health Care (NCCHC) have developed
guidelines for the treatment of HIV-infected persons.
The Mortality Reviews section of this report draws upon a standard of care that is less than
those utilized to adequately treat HIV-infected individuals.
8
LIMESTONE CORRECTIONAL FACILITY
On February 13 and February 14, 2003, I toured and observed the Limestone Correctional
Facility as a medical expert on behalf of the plaintiffs, Antonio Leatherwood, and the
plaintiff class. The review of the facility mainly consisted of observing the following:
- Dorm 16 where the majority of HIV-infected inmates are housed (approx 250);
- Substance Abuse Program (SAP) where inmates undergo drug rehabilitation
(approx 50);
- The Health Care Unit (HCU) consisting of both an inpatient and outpatient unit;
- Dorm 7, The Isolation Unit [I did not see enough of the Isolation Unit (Solitary
Confinement) to be able to provide an informed opinion]
I was not permitted to conduct any formal medical and correctional staff interviews, but did
briefly talk to both medical and correctional staff.
I will not go into much detail regarding the Limestone Correctional Facility’s history, as
this has been previously documented, but what was most striking about this facility is that
there is total segregation of the HIV positive and HIV negative inmates - something that
has been almost totally abolished around the world. The HIV positive inmates are
segregated into an HIV Dorm (Dorm 16) which is severely crowded. The population of
HIV-infected inmates in February, 2003 incarcerated in Dorm 16 was 250. Dorm 16 is an
old converted warehouse. The warehouse had previously housed the infamous “chain
gangs.” In addition, the inmates’ beds were lined up head-to-toe and very close to each
other, as well as side-by-side within a few short feet of each other. The layout of Dorm 16
is documented in photograph 1.
In addition to this severe over-crowding, the facility itself was in poor condition with many
of the windows in poor condition, as well as the doors, which clearly allowed cold air to
circulate into the facility, creating a health risk to these immunosuppressed individuals.
Numerous inmates have reported that Dorm 16 is infested with insects, spiders, and
vermin. This is consistent with the condition and physical structure of Dorm 16.
It was reported that the facility had been minimally repaired prior to the February 13-14,
2003 tour. Apparently the Limestone Correctional Facility staff and inmates had painted
some of the areas of the unit, as well as had only recently placed screens on the windows.
The Department of Corrections had also fumigated the unit given the pest problem.
Of note is that one of the major complaints arising from this unit initially was that of a
staphylococcus infection in 2002 where numerous patients had evidence of severe skin
infections including pus-filled boils. It is clearly evident that this happened due to
overcrowding and the probable influx of stinging and biting insects to the unit. Such
conditions would cause infections among HIV-infected patients. An example of this
infection is documented in an inmate patient in photograph 2.
There was a lack of adequate facilities or assistance in Dorm 16 and the Health Care Unit
for the disabled, as set forth by the Americans with Disabilities Act.
9
I also toured the Substance Abuse Program housing unit where inmates undergo drug
rehabilitation. This unit is also segregated and housed only HIV-infected individuals. Of
note again is the lack of facilities for the disabled. This unit, although crowded, was less
crowded than the HIV Dorm, and appeared to have slightly better amenities, but still far
below standard.
I spent a considerable amount of time observing the Pill Line in Dorm 16. Patients at the
Limestone Correctional Facility are administered medications at 3 a.m., 10 a.m., and 3 p.m.
The patients are made to wait outside for their medications, often in very severe weather
conditions according to many of the patients. The Pill Line I observed did seem to take a
very long period of time, making it very difficult for the weaker patients to stand in line for
their medications. The nursing staff administers medications directly into the patient's
hands. This practice is not hygienic and unacceptable. Patients were given cups that were
placed on a very dirty window sill that had mildew and obvious dirt on the surface which
obviously contaminates the cups.
The outpatient facility located in the HCU is a considerable walking distance from Dorm
16 and SAP; it takes approximately 20-30 minutes to walk between the units which creates
a potential hazard during an emergency. The outpatient unit seemed small for a facility of
this size; apparently, the physician and P.A. at one time even had to share examination
rooms at the expense of privacy for the patients.
I was also able to observe the Inpatient Unit at the Limestone Correctional Facility. After
talking with several of the patients, they reported that the emergency call buttons were
repaired just prior to our visit, and had not been working in the past. The inpatients are
often too sick to leave their beds and find a nurse, and must use some sort of remote call
device that is within reach of their beds. This practice violates accepted minimal standards
that govern inpatient units and hospitals.
A compounding problem in the Inpatient Unit is that inmates called “runners” are often
used to assist in the Inpatient Unit. This is not a problem in itself, but patients noted that
the runners are performing such duties as nourishment administration which is outside of
the scope of their training and inappropriate. This practice needs to be stopped immediately
- Nourishment should be administered only by professional nursing staff.
10
PATIENT MEDICAL CHART
REVIEWS AND INTERVIEWS ON-SITE AT
LIMESTONE CORRECTIONAL FACILITY
February 13 and 14, 2003
11
Patient Medical Chart Reviews and Interviews on-site at Limestone
Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 1
Patient’s medical records were reviewed in detail and patient was interviewed and examined on
2/14/03.
The patient is a 35 year old HIV-infected male also co-infected with chronic hepatitis C. He is
on combination therapy (HAART) consisting of nevirapine, saquinavir, and Kaletra. The doses
of these medications are correct. The patient has had a good response to HAART in that the
CD4+ T-cell count is 700 and HIV RNA (viral load) is undetectable when last assessed October
2, 2002. It is noted in the medication records that the patient has missed some doses of
medications; he reported that the HIV medications are sometimes not available. He also had
rectal warts which were removed by laser surgery on 12/2/02. Like many other patients, this
patient has apparently had outbreaks of skin infections which seem to resolve, but then reoccur.
According to the patient, he was treated on 1/28/03 apparently by nurse Hawkins with
Amoxicillin prior to her calling the physician. On examination, the patient had evidence of a
healing scar from a probable bacterial skin infection. This scar is documented in photograph 3.
IMPRESSIONS:
1. This case demonstrates that medications are apparently not always available. This is
potentially very significant for the patient insofar as his viral resistance. If the virus in
his body becomes resistant to HIV then the medications will become useless and the
patient may become untreatable.
2. This case demonstrates the severe understaffing of medical personnel. There are too
many patients with compromised immune systems for one physician and one physician’s
assistant. This patient is not monitored appropriately especially given his underlying
hepatitis C. The last time his liver enzymes were assessed was 3 months previous to the
interview and they were elevated and need to be followed more closely. The patient is
also overdue for assessment of T-cells and viral load and needs his lipid panel assessed.
3. Patients with chronic hepatitis C are at risk for fulminant liver failure if they acquire
hepatitis A or B. This patient apparently has not received a hepatitis A vaccination. This
vaccine is the standard of care for patients with Hepatitis C.
4. Nurses are not prescribers of medications; this is illegal and needs to cease.
12
Patient Medical Chart Reviews and Interviews on-site at Limestone
Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 2
Chart reviewed and patient interviewed and examined February 13, 2003. His condition is
documented in photograph 4.
This patient is a 38 year old male with Class A2 HIV infection (CD4+ T-cells 386/20% and HIV
RNA 614 on 7/17/2002). He is not on any medications for HIV (which is appropriate). The
patient also has a right leg above the knee amputation and had worn a poorly fitted prosthesis.
He is now wheel chair-bound because the prosthesis does not fit; he has been denied an
appropriately fitted prosthesis by Naphcare on 3/2/02. Mr. Stephens has reported several falls in
which he sustained injury. On 8/23/02, Mr. Stephens was seen by Dr. Simon after having fallen
8/22/02; he was noted to have left ankle swelling and was given analgesics. In her medical note,
Dr. Simon wrote: “Needs for handicap accessible shower discussed with Warden Mitchem.” He
was seen in follow-up on 8/27/02 with mild swelling of the left foot. The patient also apparently
fell in March and was not evaluated until 2 days later.
I was informed by this patient and by others that, in preparation for our visit, Limestone Prison
officials had handicapped railing installed 2/10/03 – 3 days prior.
IMPRESSIONS:
1. This patient demonstrates delay in evaluation and care of a disabled person. When this
disabled patient fell on 8/22/02, he should have been seen on an emergency basis in the
clinic – not a day later. The patient fell again in March and this time was not seen by Dr.
Simon until two days later. This is not timely and is inappropriate care.
2. This case displays total disregard by Limestone Correctional Facility for the patient and
for the Americans with Disabilities Act (“ADA”). Not having a shower that is accessible
to a disabled person is a medical issue and violates the ADA. Limestone Prison officials
ignore the ADA; this is a problem and Mr. Stephens has suffered because of this
violation.
3. Not providing adequately fitted prostheses for amputees is inappropriate on the part of
Naphcare. It will result in his becoming wheel chair-bound, fall, and further injure
himself.
13
Patient Medical Chart Reviews and Interviews on-site at Limestone
Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 3
Chart reviewed and patient interviewed and examined on 2/14/03.
This patient is a 31 year old male with Class C3 AIDS and chronic cryptococcal meningitis, a
severe life-threatening fungal brain infection. He has advanced AIDS, but had a very good
response to HAART (CD4+ T-cell count went from 54 3/6/01 to 330 8/23/02 despite having
missed doses of HAART). It is mentioned in his chart that he has had issues of
noncompliance. The patient informed me that he misses doses because he sometimes does
not hear the 3 a.m. pill line call or sleeps through it. Patients with chronic meningitis can
have decreased hearing and can be quite sleepy and can have altered mental status.
Therefore, the patient’s medication lapses can be a result of his disease progression. He also
states that he is given his protease inhibitor before meals which causes him to have nausea
and occasional vomiting. He informed me that he finds it difficult to wait in the pill line
(some times up to 45 minutes or an hour) given his chronic illness. The patient is on another
medication (ddI – brand name Videx) that must be taken on an empty stomach and 2 hours
away from a meal, but it is not being administered in that manner. This is in violation of
Food and Drug Administration (FDA) protocol for administering this medication.
Apparently in August, 2002, the patient did not receive treatment (Diflucan) for his
cryptococcal meningitis for two full weeks. According to Dr. Simon’s note dated 8/29/02,
“…it was not available”. At that time, the patient reports back pain and shows laboratory
evidence of a recurrence of worsening cryptococcal disease as evidenced by an elevated
serum cryptococcal titer of 1:128. He is placed in the infirmary and administered appropriate
medications and then slowly gets better and is discharged. As a result of the meningitis, the
patient has developed a seizure disorder and is on an anti-seizure medication (Dilantin).
However, Dilantin is a medication that has to be regularly monitored. This patient’s Dilantin
levels are not being obtained as is the standard of care.
IMPRESSIONS:
1. This patient’s case represents many of the severe problems with the administration of
medication administration disaster at Limestone and how patients’ needlessly suffer as a
result of the medication problems. Limestone simply ran out of medication for the
patient’s life-threatening meningitis. As expected, the patient’s condition got worse.
This gap in medication could have caused the patient to die. Running out of medication
for a serious infection is not acceptable.
2. The patient is not receiving his life-saving combination HIV therapy appropriately. Food
requirements and restrictions for these medications are being ignored with total disregard
for the FDA. The patient is on an anti-seizure medication yet levels are not being
obtained. This represents inappropriate medical care.
14
3. One of the side effects of the HIV medications is high cholesterol and triglycerides.
These levels have never been assessed and should be.
15
Patient Medical Chart Reviews and Interviews on-site at Limestone
Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 4
The following information was obtained from an extensive medical record review, interview,
and examination of the patient on February 14, 2003.
This patient is a 28 year old male with HIV infection who was admitted to Limestone on a
HAART regimen consisting of AZT/3TC (called Combivir) and Viracept. On 5/16/01, this
patient had a T-cell count of 563 and viral load <50 (undetectable) indicating good
compliance which resulted in an excellent response.
At some point, the patient started getting severely nauseated and was even vomiting the
medications. The medications were stopped. In particular, the patient informed me that the
HIV medications he was being administered were given prior to meals at 3 a.m. and 3 p.m.
(as opposed to with meals or right after meals) and he associates the nausea and vomiting
with taking the HIV medications on an empty stomach. This is very common in other HIVinfected patients. He further tells me that he would take the HIV medications if he were
allowed to take them with meals. According to medical records, the patient pleads to be
given food with his medications. However, this is not done. Instead, the patient becomes
noncompliant and the HIV medications are stopped.
On 12/31/01, the patient is seen by Dr. Simon and diagnosed with Shingles (Herpes Zoster
infection). Shingles is the reactivation disease of chicken pox (primary varicella) and can
spread to others who have not had chicken pox. Seven months later (3/6/02), the patient
declined immunologically and his T-cell count dropped precipitously to 260. According to
his medical records, no antivirals were prescribed for the shingles. Shingles is a potentially
severe viral infection.
IMPRESSIONS:
1. This case demonstrates the recurrent problems at Limestone with food and medication
administration at Limestone. Note that Viracept is FDA approved to be taken with food
for adequate absorption and taking it on an empty stomach can cause greater
gastrointestinal side effects. Some HIV medications, such as Norvir and Mepron, must
be taken with a large amount of fat in order to be appropriately absorbed. Many
Limestone patients, like this one, are being administered medications on an empty
stomach in the middle of the night (3 a.m.) which inappropriately leads to
noncompliance. The medications are stopped and the patient is blamed; this practice is
inappropriate and needs to cease.
2. This case further demonstrates the problem with inadequate medical care and inadequate
infection control practices at Limestone. This patient was diagnosed with Shingles – an
infection which results in blistering of the skin and severe pain. The standard treatment
16
for shingles, especially in an immunocompromised patient, is to use an antiviral agent
such as Acyclovir. Acyclovir is often the drug of choice because it is effectual and
inexpensive. The standard of care would be for this patient to be prescribed Acyclovir or
some similar antiviral and pain medication. Shingles is potentially infectious and could
present a problem in a setting (such as Limestone) where immune suppressed individuals
are housed in close quarters. The standard of care would be to isolate the patient. An
outbreak of any one of a host of potentially serious infectious diseases is possible (and
well documented) in an open ward setting and potentially very dangerous. This incident
indicates that Limestone does not follow an adequate infection control plan for
shingles/chickenpox. I am concerned that they likewise do not have adequate infection
control for TB, influenza, and staph infections. (Note that Staph outbreaks have occurred
at Limestone in the past.)
17
Patient Medical Chart Reviews and Interviews on-site at Limestone
Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 5
This patient is a 29 year old HIV+ male. His last documented CD4+ T-cell count was 253 with
viral load of 15,500 on 12/3/2. He has chosen not to be on HAART. On 1/29/02, the patient
reported a rash which progressed into a disseminated pus-filled rash around the hair follicles
(called folliculitis) and one large abscess on his thigh. He was given therapy (Keflex and warm
compresses) on 5/9/02 by Dr. Simon, but not seen again until 2 months later (7/3/02) after having
failed three full courses of Keflex by a physicians’ assistant and Dr. Simon. He was then given a
month’s course of doxycline, which is no better for treating this kind of infection than Keflex in
this setting. He was then administered a series of other antibiotics (including additional Keflex,
doxycycline, penicillin, and amoxicillin). No cultures of the pus were performed, but eventually
– 10 months later – the skin infection seems to resolve itself. This patient reports that the
dormitory is infested with flying insects and spiders. The patient also reported to me that he was
never informed of his blood test results which were obtained two months prior to the on site visit.
Upon examination, this patient has numerous scars and healing ulcerations riddling his body,
particularly the lower extremities. At the least, these scars and ulcerations are disfiguring. His
condition is documented in photographs 5 and 6.
IMPRESSIONS:
1. This case represents what happens when a health care facility with closely housed
patients has an outbreak of an infection and does not have infection control practices in
place. This patient suffered the consequences of an outbreak of (most likely) methicillinresistant staphylococcus aureus (MRSA) infection that went rampant among the closely
housed immune suppressed patients. This is one of the problems with housing these
types of patients so close together. The medical records do not reflect an outbreak
investigation. Numerous other patients had these same severe skin infections leading me
to believe this was, indeed, an outbreak of MRSA. When outbreaks such as this are not
properly contained, more infections will occur. This will lead to the deterioration of the
patients’ health. The standard of care to control infections in this setting includes: an
investigation of this outbreak, infection control practices, and cultures of the patients’
nares to assess for MRSA carriage and attempt to eliminate it.
2. The patient’s care was suboptimal. The causative agent of his infections was not
assessed.
18
Patient Medical Chart Reviews and Interviews on-site at Limestone
Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 6
The patient was interviewed and examined on February 13, 2003 at Limestone Correctional
Facility. His medical chart was reviewed.
This is a patient with HIV infection, shingles, and diabetes mellitus. When I saw the patient, he
had been complaining of having chronic nausea and vomiting, and he had not been evaluated for
quite some time. The patient had a medical order for a diabetic diet, but reports not receiving any
diabetic meals. This was confirmed by a Limestone medical staff member who told me that “all
the meals were ok for diabetics.” The patient reports that his sack lunch consists of one cheese
sandwich.
The patient is appropriately on antiretrovirals. However, he informed me that the prison nurses
often run out of these antiretroviral medications. The patient often shows up to the early morning
or late afternoon pill line, only to discover that his medications are not there.
IMPRESSION:
This patient represents another HIV-infected inmate at Limestone who also has other illnesses
and is being denied adequate medical attention through the pill line system. He reports that they
run out of his medications, as many of the other patients have concurred. Inconsistent
administration of antiretroviral medication can lead to the patient becoming resistant to the
medication. Resistant HIV can often become untreatable.
19
Patient Medical Chart Reviews and Interviews on-site at Limestone
Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 7
This patient is a 43-year-old male with HIV infection who apparently had a heart attack
(myocardial infarction) in the past. The patient was seen on September 17, 2002. At that time, he
reported chest pain, left shoulder numbness, shortness of breath, sweatiness, and nausea.
Unfortunately, the EKG machine at Limestone was not working. This was documented by a
Limestone nurse. The patient was given nitroglycerin and aspirin and was sent back to his unit.
Despite the patient being at high risk for having a heart attack, no attempt was made to get the
patient to a local facility where a simple test (and EKG) could be done and labs could be
obtained. I was unable to find whether the patient was ever evaluated again. According to the
patient, he is currently experiencing chest pain at rest, which is characteristic of possible angina.
Review of his medical records does not show that the patient has been seen by a cardiologist, and
in fact, has not received a basic cardiac evaluation. He is on multiple medications. However,
these medications are treating angina. The patient also has kidney dysfunction as evidenced by a
rising creatinine level. His medical record shows that he has not been evaluated for this
condition.
IMPRESSION:
This patient is experiencing worrisome symptoms and is clearly at high risk for having a
myocardial infarction. The EKG machine at Limestone did not work, and the patient was
inappropriately sent back to his room. He may have had a myocardial infarction, and is really not
sure whether he did at that time, but fortunately the patient did not die. Yet, he continues to
experience chest pain.
A working EKG should be a mandatory minimal component of a health care unit.
Again, this represents a patient who is not being followed in a chronic care clinic and is not
being appropriately followed-up on because the medical providers are overwhelmed and
Limestone is severely understaffed in terms of medical providers.
20
Patient Medical Chart Reviews and Interviews on-site at Limestone
Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 8
The patient was seen and examined on February 13, 2003. His medical records were also
reviewed.
This patient is HIV infected. His last T cells were drawn on 12/3/2002, when they were 271. The
patient is currently off antiretroviral treatment. The patient reports that he had previously been on
HAART at Limestone, but the medications were being given inappropriately, including on an
empty stomach. As a result, he experienced severe nausea and some vomiting. Thus, this patient
discontinued the medication. In addition, the patient was also given a nonsteroidal antiinflammatory drug. This medication was also administered on an empty stomach which caused
him to experience many symptoms.
According to the patient's medical records, he was last seen in clinic on 8/15/2002.
IMPRESSIONS:
This patient, similar to many of the other patients, is a justified frustration with the prison’s
medication delivery system. As a result, the patient is unable to take his medications. He was
prescribed antiretrovirals on an empty stomach which can cause very severe side effects.
Unfortunately the patient has a fairly advanced HIV infection and should be on antiretroviral
medications. But, he is unable to take them under these circumstances.
This also represents a patient who is not being seen on a regular basis by the medical staff. Six
months is too long for the patient to go without being seen. He should be seen on a regular basis.
Unfortunately, like many of the other Limestone patients, this patient is not seen on a regular
basis and is not seen in a chronic care clinic.
21
Patient Medical Chart Reviews and Interviews on-site at Limestone
Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 9
The patient was seen and examined on February 14, 2003 in the Limestone inpatient unit.
This patient is a paraplegic who has multiple medical problems, including HIV infection, history
of a stroke, diabetes mellitus, asthma, hypertension, and hepatitis C. The patient was evaluated in
the inpatient unit on 2/14/2003 at the Limestone Prison. The patient informed me that up until
this week, he did not have an emergency buzzer in case he needed to contact the nursing staff.
Prior to this week, he would have to “holler for a runner” if he had an emergency. The patient
also reports that he is not receiving any physical therapy. This was also confirmed in his medical
chart.
Additionally, the patient did not appear to be receiving intensive management of his diabetes.
Physical examination:
On examination, the patient clearly has difficulty with movement and has a dense, heavy
paralysis. In any kind of an emergency, the patient would have great difficulty moving.
IMPRESSION:
This patient is paraplegic and is not able to get out of bed without assistance. He has no access
to staff in an emergency, unless one of the other inmates, who serve as runners, comes to his aid.
Fortunately, emergency medical buttons were installed. However, this only occurred one week
prior to our visit. The lack of appropriate facilities for immobile or other very ill patients,
represents a potential medical disaster for the Limestone Correctional Facility.
22
Patient Medical Chart Reviews and Interviews on-site at Limestone
Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 10
This patient is a 36-year-old male who has stable HIV infection. His last T cell count was in
October 2002 when it was 358. He should have had a blood test since that time. The acceptable
medical standard is for HIV infected patients to have blood drawn every three months. The
patient was seen by me because he was complaining of shortness of breath as well as a cough.
He has a history of asthma. The patient reports that he has been trying to be seen by a medical
provider, but has not been seen. Unfortunately, I did not have access to his medical records.
Physical Examination:
On examination, the patient was clearly having some bronchospasm. This was consistent with
an asthma attack.
IMPRESSIONS:
1.
This patient, like every other patient I examined, reported having difficulty accessing the
prison’s medical system. This patient was clearly having an asthma attack. We reported
this as an urgent matter to Dr. Simon. She saw the patient and treated him for his asthma
attack.
2.
The patient also has HIV infection and is not receiving regular chronic care. Overall,
Limestone Correctional Facility’s care of the chronically ill is poor.
23
Patient Medical Chart Reviews and Interviews on-site at Limestone
Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 11
This is a 34-year-old patient with AIDS, toxoplasmosis of the brain, and a seizure disorder.
Currently, the patient is taking medications to treat the toxoplasmosis, (clindamycin and
Daraprim). In addition, the patient takes antiretroviral therapy. Unfortunately, like the other
patients, this patient is given these medications on an empty stomach, and then is told to eat his
meal. As a result, he experiences severe nausea associated with these medications.
Also, the patient reports that he often has difficulty standing in line to obtain his medications,
especially in the winter. Toxoplasmosis is a parasite which causes abscesses of the brain, as well
as inflammation, and can render the patient seriously disabled and quite ill. When not treated
appropriately, this is infection often leads to death.
IMPRESSIONS:
Again, like many of the other patients, this is a patient who is frustrated with the medication
distribution system, as well as the medical system at Limestone. As a result, he has great
difficulty taking his medications which are administered on an empty stomach. Giving these
medications in this manner is not medically appropriate and is not recommended by the FDA.
Standing in line to receive medications is intolerable for gravely ill patients such as this one. The
medical system, as well as the system of pill distribution at Limestone sets the patients up for
medication failure.
As so many others, this patient will likely be labeled (or has been labeled) “noncompliant”
despite the difficulties and near impossible environment created that do not allow him and others
to take their medications appropriately.
24
Patient Medical Chart Reviews and Interviews on-site at Limestone
Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 12
This 55 year old patient was examined on February 14, 2003. He has AIDS. He is on an
appropriate HAART regimen.
Most remarkable about this patient is that he informed me that he has had a nonhealing ulcer on
his right forearm for five years. I examined this and noted that he also has multiple skin actinic
keratoses. Upon my review of his record, he was not being treated for these conditions. His
condition is documented in photograph 7.
IMPRESSION:
The major issue for this patient is that he has a possible malignancy and is not being followed
closely enough. He, like all of the Limestone patients, needs to be followed more closely.
25
Patient Medical Chart Reviews and Interviews on-site at Limestone
Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 13
This patient is a 41-year-old male who has AIDS, hypertension, and insulin-dependent diabetes
mellitus. The patient is on an appropriate antiretroviral regimen.
This patient had been in prolonged severe pain due to an advanced untreated condition. Since
November, 2002, the patient had been reporting anorectal pain to the medical staff. He was seen
by a licensed practical nurse (LPN) on November 11, and was given Motrin. On November 20,
the patient continued to experience severe anorectal pain and was encouraged by the same LPN,
“to stop sexual activity, if he is sexually active.” It is medically inappropriate for the nurse to
make this statement instead of providing appropriate care.
The patient continued to have very severe anorectal pain, and continued to submit medical
requests to the medical providers. The patient was seen on 1/8/2003 by a surgeon. By that time, it
was found that he had a large, cauliflower-like anal wart and was given a mild pain reliever Tylenol No. 3 plus a stool softener.
When I saw the patient, the patient was unable to sit down because of severe pain. He also
informed me that he was unable to have a bowel movement.
On examination-- which is documented in photographs 8 and 9, the patient had a huge,
fungating, cauliflower-like mass which was the approximate size of a baseball in his anal area. It
was eating into the skin of his buttock area. This area was clearly very tender, and was bloody
and malodorous due to the probable underlying infection. This mass could be cancerous.
IMPRESSIONS:
This case represents yet another patient at Limestone Correctional Facility whom the medical
system has failed to treat. The patient has experienced prolonged severe pain. He is clearly not
able to understand the seriousness of his underlying disease. An untreated anal wart could be
cancerous. The virus that causes these warts is the leading cause of cancer in women (cervical
cancer) and can also cause anal cancer. He is having such severe pain that the patient is unable
to sit down or have a bowel movement. This lesion is clearly out of control, and it should have
been surgically removed at a much earlier date. However, this did not happen. This situation
illustrates an extreme case of negligence and inadequate medical care where the patient’s
condition is far advanced.
Because this patient’s medical condition was so severe, I sent an emergency letter to the medical
staff at Limestone Correctional Facility requesting that the patient be seen by a surgeon and have
this mass surgically removed.
26
Patient Medical Chart Reviews and Interviews on-site at Limestone
Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 14
This patient is an AIDS patient with a T cell count of 86. He is currently not taking antiretroviral
medications. He states that he had great difficulty taking his medications because of the early
hours the medications are administered. This patient does not understand any of the
consequences of not taking the medications or the importance of medication adherence.
Medication is especially important in a patient with a T-cell count this low. This indicates that
the patient has very advanced AIDS and that he should be on some form of antiretroviral
therapy.
The patient has also not been seen by medical staff since August 2002. This delay in medical
attention shows that he is someone who has fallen through the cracks. This patient should be
seen in a chronic care clinic on a regular basis.
IMPRESSION:
This patient does not understand the consequences of not taking his antiretroviral therapy. From
the record, it appears that no one at Limestone Prison has discussed these consequences with
him. Therefore, I do not believe that he has made an informed decision to come off of his
antiretroviral therapy.
27
Patient Medical Chart Reviews and Interviews on-site at Limestone
Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 15
The patient was examined on 2/13/2003, and his chart was reviewed.
This patient is a 36-year-old male who has HIV and hepatitis C co-infection. He reports that he
did not learn of his hepatitis C infection until his legs had swollen to the size of watermelons.
This indicates he has advanced hepatitis C and cirrhosis which is causing this swelling (edema).
Currently, the patient is on an HIV treatment regimen which is adequately dosed. Similar to
other Limestone patients, this patient reports having difficulty standing in line to wait for his
medications at 3:00 in the morning.
IMPRESSION:
The patient reports that he has worked in the Limestone Inpatient Unit. He informed me that he
has provided medical assistance to other patients in the Inpatient Unit. By all accepted medical
standards, it is completely inappropriate medical care for inmates to provide medical assistance
to other patients.
Additionally, the patient is not being treated for hepatitis C. Treatment for this virus is not
offered to patients at Limestone, although it is becoming more and more available at most
correctional institutions around the country. I was unable to locate in this patient’s records (as in
many of the others) documentation that he had been administered vaccinations against hepatitis
A and B. These vaccines must be given to all hepatitis C infected patients.
28
Patient Medical Chart Reviews and Interviews on-site at Limestone
Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 16
This patient is a 46-year-old male who has advanced AIDS, chronic hepatitis C and hepatitis B,
diabetes mellitus, hypertension, and acute renal failure. When I examined this patient on
2/13/2003, the patient informed me that he is so weak that he is unable to stand in line to obtain
his medications. The patient is currently on several medications, including antiretrovirals.
Unfortunately, there are no provisions for patients who are too weak to wait approximately one
hour for their medication. Photograph 10 documents this patient attempting to wait in line for
his medications.
The patient also informed me that he has been experiencing abdominal pain and groin pain.
However, he was told by nursing staff that he could not see a physician for two to three weeks.
The patient has acute renal failure. This condition was detected in blood work on 1/29/2003,
when the patient had a BUN of 38 and a creatinine of 2.8. Unfortunately, the patient has not had
any further evaluation of his acute renal failure.
IMPRESSIONS:
1.
This case represents a patient with multiple chronic illnesses and weakness so severe that
he is unable to stand for 30 seconds. However, he is forced to stand in line for his
medications. This will often result in the patient not being able to obtain his medications.
Unfortunately, the long pill line at Limestone is a problem for many patients.
2.
A patient who is this ill and who has acute groin and abdominal pain needs to be seen
more quickly than two to three weeks. Because of the large number of patients and the
low number of medical providers, many Limestone patients are not seen in a timely
fashion.
3.
This patient also has serious kidney failure. This patient is not being evaluated in a
timely fashion-- again demonstrating the lack of sufficient medical providers at this
prison.
29
Patient Medical Chart Reviews and Interviews on-site at Limestone
Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 17
I examined this patient on February 13, 2003, in the Inpatient Unit at Limestone Correctional
Facility. The patient has HIV infection, end-stage renal disease, and has had recent MRSA
(resistant Staph) bacteremia.
Most worrisome in this patient's history is that he initially started contacting the clinic in midSeptember when he was experiencing some skin infections. At approximately the same time,
many other HIV infected inmates at Limestone were experiencing similar infections. The patient
was not seen by Dr. Simon or the P.A. Instead, in early September, he was given a prescription
for amoxicillin as well as Motrin. The patient continues to experience these skin infections
which appear to be Staph folliculitis, as well as pus-filled furuncles and boils.
Most concerning, is that the patient reported urinary problems. In particular, he has had polyuria
as well as associated dizziness, nausea, and vomiting, which started in early November.
According to the patient's medical records and a written message to the clinic, on November 12
and 15, the patient had urinary symptoms. At that time, the patient said that he was told that he
could not see the doctor. In fact, he did not see any medical providers. He saw only the nurses.
The patient said he was not offered a urinalysis at that time, but according to the nursing notes,
did not return to the clinic to have it performed.
Despite persisting symptoms and medical requests, the patient was not evaluated for another
month. Finally, on December 18, 2002, the patient was seen by the Physician Assistant. He was
experiencing the same symptoms. Again, the patient was taking Motrin. Not until two weeks
later was the patient seen by Dr. Simon. He again complained of polyuria and other associated
symptoms.
The next day, on 12/31/2002 (nearly 2 months after his initial symptoms), the patient had a basic
evaluation which showed that he had protein in his urine. His BUN was 91, creatinine of 11.4,
with a bicarbonate of 14, all signifying that the patient had far advanced, irreversible kidney
failure.
Currently, the patient is in the Inpatient Unit, reporting that he has had increasing weakness as
well as anorexia and weight loss. He is on antiretrovirals at the appropriate doses, but
unfortunately he is hemodialysis-dependent.
Physical Examination:
On examination, the patient appeared very depressed. He did have multiple healing abscesses, as
well as healed scars that appeared to be caused by skin infections.
IMPRESSION:
30
This represents a very severe problem at Limestone Correctional Facility. Patients, such as this
one are not seen in a timely manner. It is clearly documented in the patient's chart that he was
asking to be seen by a physician or by a physician’s assistant, but was not seen and not evaluated
by them. He was not evaluated appropriately or in a timely manner. He had some early signs of
kidney failure, but again was not seen until at least 1-1/2 months after his initial symptoms. By
that time, he was in end-stage renal disease. This is an irreversible medical condition.
31
Patient Medical Chart Reviews and Interviews on-site at Limestone
Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 18
The patient was examined on February 13, 2003, and his chart was reviewed on that date.
This is a patient who has class C3 AIDS and toxoplasmosis of the brain. Toxoplasmosis is a
parasite which causes abscesses and inflammation of the brain tissue. It is uniformly fatal
without treatment. The patient carried this diagnosis for quite some time, but a review of his
chart shows that the patient had been missing many of his medications for treating the
toxoplasmosis. Upon discussing this with the patient, the patient informed me that he had been
quite frustrated with the prison’s medical delivery system. On many occasions, the medications
had not been available, or he was unable to stand in the pill line. The patient uses a walker
because of the neurologic damage and sequela that have been created by the toxoplasmosis of the
brain.
The patient had stopped taking his HIV medications (Combivir and Viracept). The patient
reports that he had taken these exact medications for many years in the past, but is currently
unable to take these medications because of his concern that he may harbor resistant HIV
rendering the medications useless. It is not mentioned in the chart whether medication resistance
has been discussed with the patient. Resistance testing has not been performed. The patient was
also taking Dilantin because toxoplasmosis can cause a seizure disorder, but the patient reports
that the dose of the medications is sometimes increased or changed by the nurses. These
medication changes are not discussed with him and he does not know if the doctor is consulted
about these changes.
Review of the patient's medical records shows that he currently is on a regimen of tenofovir,
abacavir, and efavirenz. The patient has a T cell count of 39 which was drawn in January. He is
on Bactrim, but the patient reports he does not get azithromycin for Mycobacterium avium
complex (MAC) prophylaxis on a regular basis.
IMPRESSION:
This patient is an advanced AIDS patient who has a severe brain infection with neurologic
sequela of this infection and is unable to walk or stand for more than a few minutes. He uses a
walker. But, the patient is forced to stand in the pill line for his medications. As a result, he
becomes tired and frustrated. This is probably what contributes to his not taking his medications.
Medications for severe diseases such as toxoplasmosis, need to be available to the patients every
single day. If a patient is unable or is unwilling to take a medication, this needs to be discussed
with the patient in detail. Patients may not understand why they are taking the medication, or
there may be some misunderstanding. Therefore, any noncompliance to a life-saving medication
needs to be discussed and documented in the patient's chart. This was not done in the case of this
patient. This is a huge problem. If the patient continues to not take these medications, it will
likely result in the patient's untimely death.
32
Patient Medical Chart Reviews and Interviews on-site at Limestone
Correctional Facility February 13 and 14, 2003
PATIENT REVIEW 19
The patient was examined on February 13, 2003. His medical chart was also reviewed.
This patient has advanced AIDS, hypertension, and psoriasis. I examined him in the Inpatient
Unit. The patient had been admitted to the Inpatient Unit approximately one month earlier. He
was found to have fever, headaches, and fatigue. According to the patient, he continues to
experience these symptoms. A review of the patient's medical record reveals that the patient
rarely had a temperature obtained, and I was unable to find any comprehensive nursing notes.
The patient was on Dapsone as a prophylaxis medication for Pneumocystis carinii pneumonia
(PCP). However, it appears that he was not receiving prophylaxis for Mycobacterium avium
complex (MAC). The patient had not received the medically appropriate tests and blood work for
all his symptoms. In particular he had not been evaluated for causes of fever, wasting, and
MAC. He had also not been evaluated for Cryptococcal meningitis.
Upon examination, the patient appeared rather ill. He looked fatigued. Significant exam findings
indicated that the patient had thrush. His condition is documented in photographs 11 and 12.
The patient also told me that some of the other inmates had been administering oral nutritional
supplementation to him. In addition, the emergency call system used by the patients to contact a
nurse had only recently been fixed. This was confirmed by other patients.
IMPRESSIONS:
1.
This patient is an advanced AIDS patient who has not been appropriately evaluated for
his symptoms. He should be followed more closely by the physician at Limestone. One
physician who treats close to 3,000 patients does not have enough time to give
chronically ill patients the medical care they need. In addition, the patient's inpatient
notes, including the nursing notes, were inadequate for a patient who is this ill. Nursing
is understaffed.
2.
Another issue which has come up before is that other inmates are performing duties that
should be done by the nursing staff, such as administering nutritional support, as well as
possible other physician-prescribed treatments. This is not acceptable and needs to be
stopped immediately. This represents one of the problems with the lack of adequate
nursing care that these inmates are receiving in the inpatient unit.
3.
Because of the patient's profound immunosuppression (T cells 31), and because the
patient reported fevers, fatigue, diarrhea and headaches, it was felt that the patient needed
further evaluation for opportunistic infections. As a result, I put this patient’s condition in
writing to the Limestone Correctional Facility medical officials as an emergency order.
33
SUMMARIES OF HIV INFECTED PATIENTS’ DEATHS AT
LIMESTONE CORRECTIONAL FACILITY
JANUARY, 1999 TO FEBRUARY, 2003
TAB NO. NAME
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
AGE AT DEATH
RUSSELL BATTISTE
LUIS BLANCO
JOHN BOLTON
ANTHONY COX
ANDY CRAWFORD
EZELLE DANIELS
LARRY DAVENPORT
HOWARD DAVIS
ANDREA EDWARDS
MICHAEL ELLIOT
TERRELL GREY
CHELSEA HAMMAC
EDDIE HARRIS
KELVIN HARRIS
MICHAEL HEADON
DENNIS HEARNS
CLETIS JOHNSON
LESLIE JOHNSON
MORRIS JOHNSON
STANLEY LILLIE
WILFORD LOCKETT
JOSEPH McCLURE
GEORGE McHEARD
JAMES PRYOR
WILLIE ROBINSON
TONY ROWLAND
DIONICIO SALAZAR
MILTON SMILEY
LAMAR SMITH
TIMOTHY SUMMERS
RICKEY THOMPSON
HENRY TURNER
FREDDIE WHITE
DEWAYNE WILDER
IVERSON WILLIAMS
JOHN WILLIS
EARNEST WYNN
MARVIN YOUNGBLOOD
46
44
39
39
41
60
27
48
39
36
41
34
44
44
29
32
36
45
30
47
68
71
48
36
48
30
41
43
49
32
30
35
51
37
36
35
39
39
DATE OF DEATH PAGES
12-29-2002
2-22-2001
5-22-2000
2-4-2001
5-22-2000
11-24-2002
1-24-2000
8-9-2000
10-16-2001
3-27-2001
1-25-2003
11-14-2002
5-28-2000
9-11-2001
9-19-2002
6-14-1999
5-24-2002
12-14-1999
7-24-1999
12-24-2001
3-15-2000
5-6-2002
11-12-2001
10-13-2001
11-5-2002
1-22-1999
9-16-1999
2-12-2003
1-21-2002
3-11-2002
9-2-2002
8-3-2002
6-8-1999
4-17-1999
11-15-2000
3-29-2002
2-16-2002
9-5-2000
35-36
37-38
39-40
41-43
44
45-47
48-49
50-51
52-53
54-55
56-58
59
60
61-62
63-64
65-66
67-68
69-70
71-72
73-75
76-77
78-79
80
81
82-83
84-85
86-87
88-89
90-91
92-94
95-96
97-98
99-100
101-102
103-104
105-106
107-108
109-110
34
DEATH SUMMARY
Russell Battiste
Russell Battiste is a 46-year-old male with AIDS and presumptive Pneumocystis carinii
pneumonia who died on 12/29/2002 at the Limestone Correctional Facility.
The patient was initially seen at intake by Dr. Simon on 8/7/2002. The first two notations in the
chart are “new man, poor historian.” Dr. Simon lists the patient’s medical problems as obtained
from the patient. Yet, the patient is again listed as being “a poor historian”.
After the initial intake, the patient is not seen for approximately one month until 8/7/2002. On
8/7/2002, the patient informs Dr. Simon that he is “legally blind”. In her assessment and plan,
Dr. Simon did not elaborate further regarding this condition. The patient was found to have
highly resistant HIV with a low T cell count of 81 (approximately 1000 T cells is normal). His
viral load was greater than 500,000, indicating that he had a large amount of HIV virus. He was
placed on antiretroviral therapy.
He developed an allergic reaction. This reaction was managed appropriately and the patient
recovered. Yet, on 10/17/2002, approximately three months after his admission to Limestone, the
patient was noted to have “AIDS wasting.” He was noted to be an “ill-looking male.” The patient
was diagnosed with pneumonia and started on an antibacterial agent.
On 10/22/2002 the patient worsened and was sent to an outlying hospital. At the outlying
hospital (Huntsville Hospital), the patient was quickly diagnosed with blindness in one eye from
cytomegalovirus (CMV) retinitis. He was placed on treatment for CMV so that he would not lose
the vision in his other eye. The patient was also diagnosed with presumptive Pneumocystis
carinii pneumonia and started on clindamycin and Primaquine.
The patient was returned to the Limestone Correctional Facility and on 10/27/2002, the focus of
his appointment with the physician assistant was the following: “Discharge note that the patient
wishes to be DNR, but no signed statement in chart.” At that time, Dr. McClain was called and
Decadron, which is a corticosteroid, was started. The patient deteriorated as confirmed in
multiple notes, and the shortness of breath worsened. On 11/11/2002, the physician noted that
the patient was critically ill, and a critically ill referral was filled out to be sent to Naphcare.
There is no response in the chart from Naphcare. On 11/18/2002, the patient was visited by the
“hospice team.” An advanced directive and DNR form were signed by the patient.
The patient continued to progress to worsening respiratory distress, severe respiratory failure,
and died at the Limestone Correctional Facility approximately six weeks later on 12/29/2002.
IMPRESSION:
1.
The presumptive diagnosis was Pneumocystis carinii pneumonia. The patient was only
diagnosed presumptively with PCP. When he deteriorated, even though he did not want
35
to be placed on a ventilator, it is still incumbent upon the medical staff to evaluate the
patient for other causes. However, this was not done. The patient was not sent to an
outlying hospital to evaluate for other potential diagnoses, including such treatable
illnesses as tuberculosis. The patient progressed to worsening respiratory failure and died.
This is especially concerning, given that the patient appeared to have a history of
tuberculosis.
2.
Wasting syndrome. There seems to be a common pattern at the Limestone Correctional
Facility. Patients are not receiving adequate nutrition and are wasting. They also are not
being evaluated appropriately for causes of wasting, such as infections, and are not given
appropriate supplements or medications that can increase the patient's appetite or help the
patient put on critical weight gain. This was true in this patient. The external autopsy of
this patient indicates that he weighed a mere 89 pounds at a height of 6 feet.
3.
Also concerning in these patients is the notation that he was a “poor historian.” Yet, there
is no indication that any attempts were made to obtain outside medical records for this
patient or any of the patients in which charts have been reviewed. This is concerning for
some of these patients who are ‘poor historians.’ This patient had a history of CMV
retinitis and blindness. These conditions were missed at his admission.
4.
The patient was started on an antiretroviral regimen. Yet, when Dr. Simon asked him
whether he had received one of the medications, he reported not even recognizing it. He
was not receiving a medication that had been ordered. This is an example of a pattern at
Limestone where patients either do not receive their medications, or they receive them
only sporadically.
This patient had highly resistant AIDS virus. It was likely that he would not survive a long time.
Yet, Limestone’s failure to provide adequate medical treatment contributed to his quick demise.
36
DEATH SUMMARY
Luis Blanco
Luis Blanco is a patient with chronic hepatitis B, HIV infection, and insulin-dependent diabetes
mellitus, who died at the age of 44 on 02/22/2001, at the Huntsville Hospital.
The patient unfortunately, suffered from both HIV infection and chronic active hepatitis B and
insulin-dependent diabetes mellitus. The patient was treated for his HIV infection with
combination therapy consisting of D4T, DDI, and nevirapine. The patient apparently had a good
response to these medications. He apparently had done well in managing HIV-related medical
issues, as well as from the hepatitis B, but had difficulties with his insulin-dependent diabetes
mellitus for quite some time. At one point the patient even refused to take his insulin because the
insulin was being administered, according to the patient, at times of the day that did not seem
accurate to him.
The start of the patient's demise appears to have begun on 02/11/2001 when he was seen in bed
in the Infirmary or inpatient facility. He was found to have remarkable abdominal distention. He
was given a bottle of magnesium citrate which is for severe constipation. No further evaluation
was done, but the patient was seen the following day when again the patient was noted to have
abdominal distention. Even though the patient was in the inpatient unit, he sent a medical request
form on 02/13/2001, stating that “my stomach is swollen up. I can’t eat or hold food down. I
can’t take any insulin due to me not being able to eat. Please see me as soon as possible.”
Apparently, the patient was not seen in the inpatient unit. Instead, he was scheduled to be
examined at the clinic on 02/15/2001. According to Dr. Simon’s notations, the patient was in
fact a ‘no show.’ There was no follow-up with the patient that day, until apparently the patient
was sent to the emergency room on 02/16/2001 with abdominal distention.
The notes from the emergency room were not made available, but the patient was seen and
examined, and was sent back to the Limestone Correctional Facility. At that time, the patient was
housed in the inpatient facility when he was returned on 02/16/2001. I can find progress notes
that state that this is so. Starting on 02/16/2001, the patient appeared to have continued
abdominal distention, abdominal pain and difficulty eating because the pain and distention were
so severe. He was even short of breath because of abdominal distention pressing against his
diaphragm.
On 02/20/2001, one of the nurses noted that the patient had generalized tenderness of the
abdomen. On 02/21/2001, the patient appeared to have severe respiratory distress and labored
breathing. He complained of some chest pain at that time. He was placed on oxygen, and actually
sent to the emergency room. He apparently died of an infection the following day.
There are no liver function tests present in the patient’s medical chart, even though the patient
was on antiretroviral therapy that was potentially toxic to the liver. There was also no assessment
for metabolic abnormalities such as lactic acidosis.
IMPRESSION:
37
The main issue with this patient is that he had chronic active hepatitis B and was not being
treated, despite his worsening condition. One could assume that if liver enzymes and other
appropriate lab studies had been periodically monitored, that this would have been diagnosed
much earlier than it was.
The patient was on medications potentially toxic to the liver, and these should have been
monitored more closely.
The lack of any inpatient physician documentation is a serious problem.
38
DEATH SUMMARY
John Bolton
John Bolton was a 39-year-old HIV positive male who died on 5/22/2000 at 7:47 p.m. at the
Limestone Correctional Facility. An external autopsy report from the Alabama Department of
Forensic Science stated that the patient died of cachexia (wasting) and was marked emaciated.
The patient weighed a mere 74 pounds at the time of his death.
On 4/5/200, the Mr. Bolton's health drastically deteriorated. A Health Service Request form
indicates that the patient stated that “have no problem being hungry. It’s after I eat, I have
problem keeping my food down.” The nurses noted in his chart that the patient had been
vomiting 50% of his food and that he likely had electrolyte imbalances. Despite these
observations, there were no laboratory tests obtained and no further evaluation was done other
than this cursory examination by the nurses. The patient was not referred to a medical doctor
until 4/11/2000.
The patient continued to plea for help. Yet, the medical staff did not provide assistance. The
patient submitted another health service request form several days later, reporting that he was
thinking of sugar and had no energy. He was seen by a Limestone nurse who administered a
cursory evaluation of the patient. She did not provide an adequate evaluation and did not call a
medical provider. She wrote down “no discomfort or distress observed and no plan at this time.”
Four weeks later, on 5/7/2000, the patient was admitted to the health care unit with a significant
body weight loss of more than 20%. He continued to report not being able to keep food down.
By this time, the patient was already end stage and supplementation and Megace (a medication
used to increase the appetite) was initiated. At no point was it even discussed with the patient,
nor were any medications started, to increase the patient's muscle mass. This treatment -medications to increase muscle mass -- is the standard of care for patients with wasting. Such
medications could include Deca-Durabolin or testosterone.
The patient continued to decline in the inpatient unit. End-of-life issues were never discussed
with him, or at least never documented. There was no Do Not Attempt to Resuscitate form. He
did not receive any adequate hospice care. He expired from starvation on 5/22/2000 in the
inpatient unit.
The patient also had some concomitant illnesses including bipolar affective disorder. He had
been seen by Psychiatry on 2/12/2000 because of his refusal of HIV medications. The patient
reported that he did not want the HIV medications “until he was back on the streets” which he
said would be very soon.
39
There were numerous instances in the chart where the patient presented earlier in the year, on
1/11/2000, complaining of vomiting and of not being hungry with a poor appetite. He presented
on 1/11/2000 to the physician complaining of these symptoms. Nothing was done at that time.
On 1/12/2000 he presented with probable Pneumocystis carinii pneumonia. On 1/13/2000 he was
started on a subtherapeutic dose of Bactrim (double strength two times a day). His Bactrim dose
was later increased to three times a day. This was started because the patient had fever, shortness
of breath, and a disease process in his lungs. However, the patient never received a diagnosis
during this time. According to records, he stabilized on the subtherapeutic dose of Bactrim.
No definitive diagnosis of this patient was ever made.
IMPRESSION:
The focus of this review has been directed to the events that led to the patient's death. The focus
has not been diffuse. There are many other issues in this patient's medical records signifying lack
of care or inadequate care.
The most concerning part of this patient's care was that he clearly presented early in the year
2000 with difficulty eating and lack of appetite. This was not addressed adequately, even though
in February 2000 the patient had a T cell count of 15. It was not until several months later, in
May 2000, when the patient was admitted to the inpatient unit and was provided appetite
stimulants. By this time, the patient was already dying and had lost such an extreme amount of
weight that no course of therapy could reverse his course of wasting.
There have been multiple patients who have died of wasting at the Limestone Correctional
Facility. This addresses the issue of inadequate nutrition, inadequate diagnoses, work-up and
treatment of wasting at the Limestone Correctional Facility. There are simple medications that
can be used to treat wasting and increase the patient's body mass. While it is true that patients
still die of wasting in the free world, it is concerning that there are such a large number of
patients at Limestone rapidly dying of this ailment.
In addition, the patient's treatment in December, when he presented with a febrile illness and a
lung process, is concerning in that the patient was not appropriately evaluated, nor was he treated
appropriately. Patients with a low T cell counts presented with a lung process, need a diagnosis.
Instead, this patient was presumptively diagnosed with Pneumocystis carinii pneumonia. He was
started on a subtherapeutic dose of Bactrim. He apparently showed some improvement. But this
is inappropriate medical care. This patient’s demise was premature.
Finally, this is another patient whose end-of-life care and DNR issues or Advanced Directive
was not addressed.
40
DEATH SUMMARY
ANTHONY COX
Anthony Cox was a 39-year-old male with AIDS who died at the Huntsville Hospital on
2/4/2001.
The patient had AIDS with a very low T cell count (less than 50), and multiple complications of
HIV, including AIDS wasting, esophageal candidiasis, thrush, cytomegalovirus (CMV) retinitis,
end-stage renal disease (kidney failure) on hemodialysis, and Staphylococcus bacteremia. The
focus of this summary will be on the patient's last few months of care.
As noted by multiple health service request forms, the patient pled for assistance from the health
services personnel multiple times. Beginning on 9/13/2000, the patient sent a request to the staff
stating “my vision in both eyes are blurry, especially in the left eye and needs to be seen by the
doctor.” He was evaluated by an LPN and was noted to have 20/20 vision in both eyes. This
result is highly suspect given that the patient ultimately was diagnosed with CMV retinitis – a
blinding disease of the eye caused by a virus.
Just four days later, on 9/17/2000, the patient continued to have problems and in an additional
health services request form the patient stated, “I am having bad blurry vision in both my eyes. I
believe it is CMV and I want my medicines changed…” The LPN did not see the patient, but
wrote a note to see the prior health services request form. The patient was not even evaluated.
The patient continued to plea for help. On 10/16/2000, the patient again reported, “I’ve stated
I’ve got CMV which my eyesight is getting worse. I see this as neglect. I must be seen by Dr.
Simon about my problem. It’s urgent.”
On 10/25/2000, the patient again reported, “My eyesight is worser than before. I’ve been having
this problem since early September 2000 and something must be done about it. Needs to see the
doctor.” The LPN reports that the patient was ready “to see the eye doctor. Doctor unable to see
everyone on first visit. To return in November.” This statement demonstrates a lack of caring,
neglect and a lack of understanding on the part of the nurse of the seriousness of this patient's
complaints, who clearly understood that he might have sight-threatening CMV (and who
ultimately was diagnosed as having CMV retinitis).
The patient was finally seen by Dr. Simon on 11/25/2000, which was more than three months
after his initial request. At that time, he was reporting decreased vision and he reported only
being able to see shadows. He was scheduled to be seen by an optometrist, but the optometrist
canceled due to “bad weather” as listed in the note. Appropriately, late in the course of the
disease, the patient was sent to the hospital. However, the patient was still not diagnosed with
CMV retinitis or initiated on therapy until five days later on 12/30/2000, even though the patient
clearly had loss of vision and was at risk for losing total vision.
41
On multiple occasions in this patient’s medical record (as in the medical records of other
patients), there are notes regarding noncompliance. It is evident that patients had difficulty being
compliant at the Limestone Correctional Facility. On 6/28/2000, this patient was counseled about
noncompliance. His response was “he can’t hear sick call and sleeps through it.” The nurse who
evaluated him at this time did not address his noncompliance any further. It is very difficult to
evaluate the medication administration record forms in this patient’s medical chart, but it appears
that indeed the patient was not fully adherent to his medication regimens. This is similar to many
other patients at Limestone.
On 10/4/2000, the patient complained of diarrhea. He was seen by the physician. As has been
indicated, he was not given any work-up, but was instead treated symptomatically. At that time,
he had also been complaining of decreased vision. A cursory exam was done by the physician
who reported no lesions, even though this was a suboptimal way to diagnose CMV disease. She
did not work-up the patient's complaints.
On 1/11/2001, the patient complained of shortness of breath and became ill. He was started
empirically on Bactrim, as many of these patients were. He did not receive a diagnosis.
Unfortunately, at the Limestone Correctional Facility, IV Bactrim was not available that day so
he was put on oral Bactrim. He went on to decompensate and on 1/12/2001, his shortness of
breath worsened. He went into respiratory failure and was taken by ambulance to the local
hospital where he died on 2/4/2001.
There is no external autopsy and no information available from the patient's hospitalization at
Huntsville Hospital.
IMPRESSION:
This patient represents a well established pattern of patients who presented with either critical
laboratory values or very serious symptoms such as decreased vision, who were not
appropriately evaluated at Limestone Correctional Facility. Unfortunately, the nursing staff and
medical staff were unable to recognize the seriousness of an advanced AIDS patient who
complained of decreased vision. This was indeed a medical emergency, and these patients
needed to be evaluated emergently.
This patient's loss of vision could have been saved had he been treated earlier. However, this did
not occur. His pleas for help, written on the health services request forms, were ignored, even
though the patient was able to self-diagnose his own CMV retinitis. Unfortunately, the medical
staff was incapable of making this diagnosis until late in the course of the disease. This,
combined with the lack of an organized health care system, leads to a pattern of deadly diseases
being diagnosed late or not at all, being treated inappropriately and ultimately to higher
morbidity and mortality in this population.
This patient was noncompliant. This is a common theme at the Limestone Correctional Facility.
High instances of patient noncompliance question the therapeutic relationship or lack thereof,
that exists between the patient, the medical system and the staff at Limestone Correctional
Facility. There was an extraordinary attempt to document noncompliance. Yet, little or no
42
attempt was made to remedy noncompliance or try to help the patients have access to their
medications. Instead, patients are warned against noncompliance, and ultimately medications are
withheld and discontinued and the patient is blamed. This, despite the fact that the situation the
patients are in makes compliance difficult, if not impossible in the long-term.
In reviewing some of the older notes, this case also brings up the issue of poor medical records
and the lack of transcription services at the Limestone Correctional Facility. I have not seen one
note transcribed, which causes many difficulties in interpreting the notes. This creates a medical
file which is difficult or impossible to read.
In addition, problem lists are not filled out regularly. Medication lists are not regularly filled out
or updated. Such basic prevention measures as vaccinations are rarely documented in any of
these patients. It is clear from the medical records at the Limestone Correctional Facility that the
medical facility is highly disorganized and many patients are falling through the cracks. The
patients that are being seen, are not being adequately evaluated because of a substandard and
antiquated system.
43
DEATH SUMMARY
Andy Crawford
Andy Crawford was a 41-year-old male who died on 5/22/2000 from complications of AIDS. He
was only at the Limestone Correctional Facility for one night. His history was obtained from
scant medical records. It is important to review his medical care prior to arriving at Limestone.
The patient was originally sentenced on 3/13/2000 and held at the Montgomery County Jail until
5/1/2000. He was then transferred to the intake center at the Kilby Correctional Facility. At
Kilby, he was held for one week until 5/9/2000. It was clearly documented that he was seen by a
physician and noted to have a decreased level of consciousness. It was also noted by the
physician that the patient was lethargic prior to his transfer and was urinating on himself
(incontinent of urine). However, he was transferred to the Limestone Correctional Facility where
he was held overnight. He was then transferred to the Cooper Green Hospital. Mr. Crawford
expired two weeks later.
Although there are few medical notes addressing this patient, because of his short stay at
Limestone, the notes that can be reviewed are revealing and problematic.
Upon intake, the patient was seen at the Limestone Correctional Facility and was noted to be
lethargic and nearly unresponsive. He was also incontinent of urine. Upon reviewing his
condition prior to transfer from the Kilby facility, his medical status was similar. At Kilby he
was noted to have a decreased level of consciousness. Despite the patient appearing very ill and
experiencing decreased levels of consciousness, he was still transferred to Limestone.
The patient received an external autopsy examination. The autopsy noted that the patient had a
history of toxoplasmosis of the brain. However, the records do not indicate that he was
transferred to Limestone on any anti-toxoplasmosis medications.
Upon being received in this condition at the Limestone Correctional Facility, the patient was sent
to the hospital. He died shortly thereafter.
IMPRESSIONS:
This patient's case clearly demonstrates the systemic problems in the Alabama correctional
facilities. These two facilities are transferring and accepting patients inappropriately. This patient
should not have been transferred from the Kilby facility, and should not have been accepted in
transfer by the Limestone Correctional Facility. He was transferred without nursing or any other
kind of skilled medical care. He was transferred by correctional officers and it was surprising
that this patient did not become even more ill during his transfer and require an emergency stop
at a hospital.
44
DEATH SUMMARY
Ezelle Daniels
Ezelle Daniels was a 60-year-old male who died of AIDS on approximately 11/24/2002. An
external autopsy or summary of his death was not available in his medical records.
The patient was received at the Limestone Correctional Facility on 6/19/2002. Although this
patient had advanced AIDS with a T cell count of 23, hepatitis C and multiple medical issues and
complaints, he was not seen until a full month later on 7/18/2002 by Dr. Simon. On 7/18/2002, it
was recorded in Dr. Simon’s note that the patient had multiple medical problems. Dr. Simon
indicated in her physical examination that he was a thin male and that he was edentulous (he had
no teeth).
There was no referral for the patient to be fitted for teeth and no provision made to alter his diet
so that he could receive food that he would be able to eat. His extremely thin body habitus was
also not addressed.
The patient was not seen again until almost one month later. At that time, the patient had been in
the Limestone Correctional Facility for two months. As stated above, his T cell count had been
obtained and was found to be quite low at 23 with a viral load of 73,000. The patient was started
on Pneumocystis carinii pneumonia prophylaxis, Mycobacterium avium complex prophylaxis
and an antiretroviral regimen.
There is no documentation in the chart that there was any attempt made to obtain the patient's
outside laboratory results. In addition, there was no attempt made to determine the patient's prior
antiretroviral regimen. The patient spent a full two months at the Limestone Corrections facility
without HIV medications and at risk of acquiring deadly, yet preventable, opportunistic
infections such as Pneumocystis carinii pneumonia or Mycobacterium avium complex.
The patient submitted a health service request form on 7/18/2002 requesting double portions of
food because of his profound weight loss. However, Dr. Simon did not address this request and
did not increase his food portions.
On 8/30/2002, the patient reported fever. Dr. Simon noted “the patient is shaking under his
covers...but is in no apparent distress.” This is a contradictory statement. A chest x-ray from 10
days earlier reflected what was believed to be a pneumonia. There is no documentation in the
chart that the suspected pneumonia was addressed at that time. Therefore, there was a 10-day gap
between radiographic documentation and the prescribing of treatment. Despite the 10-day gap,
the patient was started on treatment for pneumonia and he subsequently improved.
45
Finally on 9/05/2002 he was diagnosed with AIDS wasting and started on oral supplementation
with Resource. Resource is a protein drink. On 9/13/2002 the patient continued to experience
wasting and diarrhea. The diarrhea was not evaluated for parasites or bacterial infection which
can cause devastating illness in AIDS patients. Instead, the patient was placed on anti-diarrheal
medications which treat the symptom, but not the cause of the diarrhea.
In a physician’s note on 10/07/2002, there is a notation that the patient was observed returning
his tray with almost all the food still on the tray. The patient was questioned about this. The
patient noted that the food was too hard and he could not chew it. It was again noted that he was
edentulous and therefore had no teeth with which to chew his food. The patient was referred to a
dentist for dentures. This referral for dentures occurred almost three months after the patient was
noted to be edentulous on his first physician visit.
On 10/07/2002 there is a request for an Ensure form. According to the records, Ensure is
something that needs to be specially requested from Naphcare. This note describes in vivid detail
how emaciated and how sick the patient was at this time. It states that the patient was wasting,
that he had prominent cheekbones with no visible fat and decreasing muscle. In parentheses it
states “wasting.” The records indicate “rib cage very visible.” He apparently was 5 feet 8 inches
and weighed 98 pounds. His ideal weight was 160 pounds. This indicates the patient had lost
approximately 30 percent of his ideal body weight. Such weight loss has profound medical
complications for an AIDS patient.
The emaciated patient declined in health. He never received his dentures. Consistent with many
Limestone patients, he did not receive any end-of-life care. He did not receive any life-saving
medications to increase his muscle mass. He expired on 11/24/2002, from AIDS wasting
syndrome.
IMPRESSION:
This is a disturbing but common event at the Limestone Correctional Facility where patients are
admitted with AIDS and decline rapidly. This is not the norm in the developed world. Patients
with AIDS typically do not deteriorate this aggressively and rapidly, at least, not in the United
States where modern medications are available.
This patient did indeed have advanced HIV, but he went without treatment for one month at the
Limestone Correctional Facility before he was seen by a doctor. He was at the facility for two
months without receiving any medications. He was at the facility for almost four months before
he was even referred to a dentist for dentures because he was unable to chew the food he was
provided.
The patient’s Limestone records indicate that his outside medical records were not requested or
obtained when he first arrived at Limestone Correctional Facility. Indeed, there is no indication
whether there is adequate support at the Limestone Correctional Facility for the physicians and
staff to even request outside medical records. If not, that is a serious flaw in a working medical
system of care.
46
As early as July, Dr. Simon did not address this patient’s request for double portions of food. Dr.
Simon ignored this request. Yet, in her medical records she clearly described the patient as being
thin. As the treating physician, it was incumbent upon her, to address this request at the time it
was made. Dr. Simon also should have addressed his lack of teeth and made the referral to obtain
the patient dentures, especially when Mr. Daniels was seen by her and questioned and was
informed by him that he was unable to chew his food. This patient died most likely of AIDS
wasting which was exacerbated by the lack of adequate medical and nursing care, lack of
treatment, lack of adequate nutrition and the lack of life-saving medications to increase his body
mass. In this patient, a lack of teeth made the situation only worse.
47
DEATH SUMMARY
Larry Davenport
Larry Davenport was a 27-year-old male with AIDS who died of septicemia (commonly called
bacteria in the blood or blood poisoning) on 01/24/2000 at the Huntsville Hospital. He had only
been incarcerated at Limestone since 12/10/1999.
Mr. Davenport had a history of AIDS and a recent hospitalization for Pneumocystis carinii
pneumonia. He also had pancytopenia which means that his blood counts were all very low, and
a history of hypertension. Upon intake, the patient was seen and only given a cursory evaluation.
He had a laboratory blood draw on 12/15/1999. There is no documentation of medical staff or
patient follow-up.
None of the medical records show that the patient was placed on medications during this time
period. There was also no documented attempt by the Limestone Correctional Facility to obtain
medical records from the outside hospital, even though the patient was transferred directly from
the hospital into the Limestone Correctional Facility, bypassing the Kilby Correctional Facility.
On 1/12/2000, the patient presented with high fevers. He was put in the inpatient infirmary and
was quickly started on an antiretroviral regimen, as well as prophylaxis for Pneumocystis carinii
pneumonia and Mycobacterium avium complex. It is important to note that this antiretroviral
regimen was started a full month after his laboratory results were drawn which showed an
extremely low T cell count of 24.
Throughout the patient's stay in the infirmary, and in fact on 1/12/2000, Dr. Khouri’s notes
questioned whether the patient had Mycobacterium avium complex (MAC). Given the low T-cell
count, the patient could have had MAC. At some point, an additional antibiotic was started.
However, the patient continued to decline. He continued to experience extremely high, spiking
fevers, but according to the medical record, the patient had not been given an adequate work-up.
In fact, only one blood test was drawn. No additional blood cultures were obtained, which is the
standard of care. The single laboratory test was drawn on 01/18/2000 that showed the patient had
bacteria in his blood. The patient was transferred to a local hospital where he died of sepsis six
days later.
IMPRESSION:
This is an example of another patient at Limestone Correctional Facility who had an incredibly
rapid and fatal decline. Despite being transferred directly from a hospital, it is clear that the
medical staff at Limestone Correctional Facility did not attempt or did not receive an adequate
history regarding this patient’s recent hospitalization. In addition, the medical staff was grossly
negligent in that the patient was not followed closely, even though he was presented to the
infirmary with such high fevers and in such extremis, to die so rapidly. This was a very young
patient, only 27 years old, and he died a very rapid death and preventable death.
48
There is one indication in the medical records of the patient hoarding his medications toward the
end, which more than anything, signifies the patient's mistrust in the medical system, given that
when he was questioned about this, the patient reports no problems with his medications. The
patient was critically ill on 1/21/2000. Yet, the nurse was not making sure that this patient was
being administered his medications. The patient died only three days later.
49
DEATH SUMMARY
Howard Davis
Howard Davis was a 48-year-old male with AIDS who died on 8/9/2000. An external autopsy is
not available in the records that have been reviewed.
The patient was HIV positive with a very low T cell count (less than 50), as well as presumptive
toxoplasmosis of the brain. The patient also suffered from chronic obstructive pulmonary disease
(COPD), significant psychiatric illness and had a long history of noncompliance.
A thorough review of the patient's chart clearly demonstrates that the patient had a long history
of noncompliance with medications. In addition, the patient had a rather extensive psychiatric
illness which was not well delineated in the medical records. However, at one time in 1996 and
1997, he was on Mellaril and amitriptyline and thioridazine which are administered to patients
with significant psychiatric illnesses. The patient had been prescribed medications to prevent
Pneumocystis carinii pneumonia and medications to prevent Mycobacterium avium complex. He
had also been on multiple antiretroviral regimens.
A note in the chart on 8/3/1999 is representative of the patient's history. It states “noncompliance
with Septra” and states he did not need Septra. This medical advice was made when the patient
had a low CD4 and high viral load. Septra was needed to prevent Pneumocystis carinii
pneumonia. “He stated he understood and he would not take it because he did not need it.” This
note was written by an LPN.
This note is concerning because the LPN was not really sure whether the patient understood the
ramifications of not taking his medications. In addition, the patient did not undergo psychiatric
assessment. At any rate, three months later in 11/1999, a note written by a physician reported a
discussion with the patient regarding antiretrovirals. The patient said he understood and will
“pass again”. From this note, the physician is unsure of whether the patient understands the
medical advice being provided, or whether the patient had confidentiality concerns or other
issues.
IMPRESSION:
This is a patient at the Limestone Correctional Facility who has an extensive history of
noncompliance with his medication regimen. He had been provided opportunities to take his
medications. What is unclear is why the patient was unwilling or unable to take his medications.
This patient may have been distrustful of the system and as a result, decided not to take any of
his medications throughout his stay at the Limestone Correctional Facility.
50
Confidentiality could have been another issue caused by pill line. At any rate, these issues were
in fact not discussed with the patient. Over the course of several years, medications were
initiated and then later discontinued because the patient was noncompliant. The patient is
partially responsible for his noncompliance and patients must take their own medications, but
this patient clearly had a history of psychiatric disease and ultimately died of a history of
toxoplasmosis of the brain which affects neurocognitive functioning, the effects of toxoplasmosis
could have compromised his judgment.
51
DEATH SUMMARY
Andrea Edwards
Andrea Edwards was a 39-year-old male who died at the Limestone Correctional Facility on
10/16/2001.
The patient was HIV positive. He died of AIDS wasting syndrome. The patient's illness was
complicated by AIDS dementia, severe thrombocytopenia (which is low platelet count), anemia,
and liver dysfunction.
The patient had a rather long previous incarceration. His most recent incarceration started on
3/12/2001, when the patient had a blood draw. At that time the patient was found to have a very
low T cell count and a high viral load. The patient was seen in follow-up by the physician on
4/5/2001 and was found to have a urethral infection. His T cell count was 10 and his viral load
was over half a million. The patient at that time did not want to start antiretrovirals, agreed to
start Pneumocystis carinii pneumonia and Mycobacterium avium complex prophylaxis. There
was no indication as to why the patient did not want to start antiretrovirals.
The patient was seen again in follow-up on 5/31/2001. It was reported that the patient was not
coming to the pill line. Again, the physician’s note does not discuss why the patient was not
coming to the pill line, nor was there a psychiatric assessment for depression or for his mental
status. Yet, a licensed practical nurse (LPN) discussed Do Not Resuscitate (DNR) issues, and
reports that the patient just wanted to think about it at that point, and specifically did not want to
be placed on Do Not Attempt to Resuscitate (DNAR) status. This is problematic because it is
not the role of a LPN to discuss such an important issue with a patient.
On 6/3/2001, the patient was seen by the physician and diagnosed with AIDS wasting syndrome.
At that time, he had not been receiving any therapy. He was housed in the infirmary until his
death. Even though the patient was diagnosed with AIDS wasting until his death, he was not
started on any oral supplementation or any medications to increase his lean muscle mass.
On 8/8/2001 he was seen by the physician who described the patient as “an emaciated male,
looking pale and weak.” He was diagnosed with AIDS wasting and anemia. A few days prior he
was started on Ensure which is a protein supplementation. The patient was followed again on the
inpatient unit. He continued to decline.
The issue of DNAR was again discussed with the patient. The patient declined DNAR status.
On 10/3/2001 the patient was found to have a critically low platelet count of 11,000. The
following day, the patient was started on prednisone to help increase his platelet count. On
10/5/2001, the physician reported that she had ordered some labs that were not sent and that she
had to reorder those labs. The patient continued to decline. He received minimal nursing care and
no hospice care. He expired on 10/16/2001.
52
As a final note, the physician noted that considering the clinical picture and prognosis,
cardiopulmonary resuscitation (CPR) was not attempted. The patient was pronounced dead.
IMPRESSION:
Mr. Edwards was a very advanced AIDS patient who, like many other patients at Limestone, had
a rapidly progressive decline in health. His most bothersome symptom was his AIDS wasting.
Many other patients at Limestone have also demonstrated symptoms of AIDS wasting. He was
not treated appropriately or aggressively. The patient received some minimal protein
supplementation, but no medications were provided to increase his appetite or increase his
muscle mass. These medications can be life saving. The patient was clearly noncompliant, yet
there was no indication in the medical record of discussing the patient's noncompliance and
whether he understood why he was on these medications. In addition, this is a pattern at
Limestone Correctional Facility where many patients appeared to be unable to stand in line for
their medications, and appeared to not receive their medications as a result.
Medical orders from doctors (such as laboratories) are often missed at Limestone as was the case
with this critically ill patient.
As is the pattern at Limestone, while the issue of DNR was discussed with this patient and
documented, the patient’s wishes to not be DNAR were not respected.
53
DEATH SUMMARY
Michael Elliot
Michael Elliot was a 36-year-old male who died at the Huntsville Hospital on 03/27/2001 at
11:00 a.m.
Although medical records are not available from the patient's hospital stay, a review of the
patient's external autopsy report shows that he died of Pneumocystis carinii pneumonia and that
he suffered from AIDS, Cryptococcal meningitis, AIDS dementia, and depression. This is one of
the few patients reviewed who signed a Living Will. The Living Will was signed on 3/7/2000.
A review of this patient's extensive medical history shows that he was on multiple antiretroviral
therapies and other treatment regimens. He was seen repeatedly by the nursing staff and
occasionally by the medical staff addressing noncompliance of his medication regimens.
The patient was not capable of taking a one medication a day regimen to prevent Pneumocystis
carinii pneumonia or to treat his Cryptococcal meningitis. Indeed, he was not capable of taking a
complicated regimen to treat HIV. Most of the regimens to treat HIV involve medications which
must be taken at least three times a day, with special attention to food intake.
This patient had great difficulty adhering to medication regimens which is reflected throughout
the patient's chart. There is only one instance in the medical records where the patient received
any counseling to help increase his adherence or to discuss what some of the issues were
addressing his adherence. Most medical providers recognize these steps as necessary for
noncompliant patients.
On 4/4/2000, a note in the chart by an LPN states, “noncompliance with antiretroviral
medications and Septra,” [which is Pneumocystis carinii pneumonia prophylaxis]. “Inmate
signed release of responsibility. Antiretroviral medications DC’d. Septra DC’d due to
noncompliance.” It is very concerning that the patient's medications were completely
discontinued despite his not being counseled on this issue. Discontinuing a patient’s medications
are not within the scope of responsibility of a licensed practical nurse. This should have been
addressed by the physician, or at least by a pharmacist.
Several instances are also documented in the patient's chart referring to a “counseling report.” In
the counseling reports, there are warnings called “first warning” or “second warning” or “third
warning.” These warnings are filled out by LPN’s. However, all the LPN does is fill out the
form. The LPN does not counsel the patient addressing noncompliance. Then the LPN reports
that the patient needs to be more compliant with medication treatment or be subject to
discontinuation of medications. It is clear from the records that warnings are used as threats to
the patient, and are not utilized to increase the patient's understanding or cooperation of
noncompliance with their medication.
54
While the patients need to be adherent, need to take their medications and need to recognize that
it is necessary to take their medication on a regular basis, these types of warning tools used by
the Limestone LPN’s are clearly not helpful to the patient.
On 3/7/2000, the patient presented to the physician with a differential diagnosis of pneumonia
versus tuberculosis. The following day, the physician ordered an antibiotic which apparently was
not available at the Limestone pharmacy. However, even though the drug was not available, the
doctor was not informed about the unavailability. Thus, the patient was never given the
antibiotic. The patient was administered medication for presumptive Pneumocystis carinii
pneumonia, although he was not diagnosed with that date. The diagnosis of PCP is typically
made by induced sputum or an invasive procedure called a bronchoscopy. PCP is not diagnosed
according to symptoms.
Without a diagnosis, the patient declines fairly rapidly over the next few days. On 3/11/2000 his
oxygen saturation was 71% on five liters. At this time, he was appropriately sent to the local
hospital for treatment. However, his presumptive pneumonia was so severe that he eventually
died on 3/27/2000.
IMPRESSION:
This 36 year old patient presents a classic example of a noncompliant patient at Limestone
Correctional Facility where the patient's reasons for noncompliance were never determined.
Throughout the patient's medical record, it is clear that he was unable to take his medications -even a simple pill once a day. Yet, no medical or nursing staff ever discussed with him the
importance of taking this medication, or such discussions were not documented in the chart.
This calls into question the effectiveness of the system that currently exists at Limestone
Correctional Facility where all patients must stand in line for their medications, regardless of
their medical condition or ability to comply. Many correctional institutions in the United States
have adopted a system of treatment where patients are allowed to keep their own medications
and are allowed to administer their own medications. In many ways, this increases the patient’s
feeling of responsibility and increases the patient's adherence, given that it makes it much easier
for the patient to take their medications, especially such simple medications as an antibiotic once
a day to prevent pneumonia. This patient likely died of a pneumonia which was 100%
preventable -- Pneumocystis carinii pneumonia.
This could have been prevented, yet it was not because the patient was not capable of taking his
Pneumocystis carinii pneumonia prophylaxis. Despite the patient’s responsibility, it is also the
responsibility of the correctional institution to assist patients in taking their medications and to
create a healthy therapeutic environment to allow patients to take their medications, especially
the patient who is more vulnerable or who may have underlying psychiatric illness such as this
patient who was depressed and who had AIDS dementia, or who might not understand the
consequences of his actions.
55
DEATH SUMMARY
Terrell Grey
Terrell Grey a 41-year old HIV-infected patient who died at an outlying hospital on 1/25/2003 at
12:40 p.m.
The significant part of this patient's medical history started in November 2002 when the patient
was discovered to have cotton-ball lesions on both lung fields. This condition was discovered
during a routine chest x-ray. The initial belief was that the patient may have metastatic cancer to
the lungs. However, the patient never had an adequate evaluation which would have included a
tissue diagnosis. Approximately one month later, the patient had a chest CT scan which revealed
that the patient had some large lesions that might have been consistent with metastatic lung
cancer.
The patient was seen by Dr. Simon on 1/25/2003 at 6:00 a.m. He was experiencing shortness of
breath after being exposed to a large amount of dust caused by a piece of the ceiling that fell in
his housing unit. The patient was placed on oxygen and was given albuterol. He improved
somewhat. However, he was placed on a large amount of oxygen at 4 liters per minute. In Dr.
Simon’s chart note from that day, it is noted that he had an oxygen saturation of 85% and a blood
pressure of 100/60. A normal oxygen saturation is above 95%. 100% is an optimal normal level.
Dr. Simon then left the prison and instructed the nurses that if the patient’s oxygen saturation
became less than 80%, he was to be sent out to the emergency room. It is unclear from the
medical records how this number -- 80% -- was decided. At 8:30 a.m., as set forth in the nurse’s
note in the chart, the patient was sitting on the side of his bed with shortness of breath. He was
using his intercostals (rib) muscles to breathe, meaning that he was having great difficulty
breathing. This is something that is often seen in patients who have very severe emphysema. The
patient's oxygen saturation was 88% while on four liters of oxygen. 88% is a low saturation
number. Also, the patient's skin color was ashen, signifying severe respiratory distress.
According to the notes in the chart, even though the patient was clearly in respiratory distress,
the nurses observe “no respiratory distress noted at this time.” The vital signs were obtained. The
patient's pulse was 120 and respirations were 26. Normal respirations are usually about 1/2 of
this amount.
One-half hour later, at 9:00 a.m., the nurses noted that the patient was anxious and was breathing
through his mouth. Oxygen saturation was extremely low at 74% with a very high pulse rate of
144. It was then decided that the patient would be transferred to the hospital. The patient's
oxygen saturation dropped even lower to 69% when the patient was being transferred from the
concentrated oxygen to portable oxygen. His respirations increased to 38 with a low blood
pressure of 98/50.
56
At 10:20 a.m., the nurse’s note in the chart states that the patient tolerated his transfer from the
wheelchair to the Department of Corrections van quite well. However, this observation is not
supported in their other notes in the chart. The portable oxygen tank was placed in the van.
Officer Timothy Howard was concerned about the instability of the patient and actually makes a
statement to the nurses, and there is a signed statement on 2/1/2003. In fact, the officer noted that
“I saw the patient get out of bed one time to utilize the toilet. He appeared to be weak with
labored breathing at that time. Inmate Gray had an oxygen SAT monitor on his index finger and
it read 79, down to 72, and stayed between the two every time I looked at him.”
The officer continues, “I stated to Nurse Smith, if Inmate Gray is that bad, shouldn’t he be
transported in an ambulance.” Officer Howard, in his signed statement, states that Nurse Smith
told him that “He’ll be fine!” Office Howard then stated “I stated to Nurse Smith that the two
officers transporting Inmate Gray do not have medical training to be able to transport an inmate
with the problem that Inmate Gray was having. Nurse Smith stated, ‘He’ll be fine. I’ll put some
oxygen in the vehicle with him and let him roll. He will be fine.’”
The two officers started transporting the patient. Instead of taking him to the nearby Athens
Limestone Hospital, the officers were instructed to take him to Birmingham-- two hours away.
Soon after the patient was en route, Officer Kossi and Newman who were transporting the
patient, noted that the patient appeared quite ill. They noted that his eyes rolled behind his head.
The officers were in a quandary about what to do. The officers decided to stop at a store to ask
for the location of the nearest hospital. The patient was in respiratory arrest and in need of
cardiopulmonary resuscitation. The officers stopped at the nearest hospital, which was the
Woodland Medical Center.
The patient was removed by the Woodland Medical Center nurses approximately 30 minutes
after going into cardiopulmonary arrest. The nurses attempted CPR. No CPR was attempted prior
to the patient's arrival at the hospital. Even though the staff at the Woodland Medical Center
made a valiant effort, the patient died soon thereafter.
A review of the chart reveals a signed statement by Mary Jones, LPN. The nurse states that she
was asked by Ms. Elizabeth Smith to look at Inmate Terrel Gray. She reports that when she
entered his cell, she observed a solemn facial expression with an ashen gray skin color. Nurse
Jones further states that the patient's oxygen saturation was between 74% and 79% with a high
pulse between 133 and 144. The patient’s blood pressure was very low at 98/50. The nurse’s
assessment is “no respiratory distress or cardiac distress was observed, but I do suggest we go
ahead and send him to the hospital.”
Then the nurse states “The inmate was sent to the hospital via Department of Corrections van for
follow-up care. No indications were present for need of ambulance or emergency van.”
IMPRESSIONS:
This is another example of a patient at Limestone Correctional Facility who was permitted to
suffocate without receiving appropriate therapy. An oxygen saturation in the 80’s -- much less in
the 70’s or 60’s -- on four liters of oxygen is very low. At this time, the patient was critically ill.
57
However, the patient was allowed by the nurses and by Dr. Simon to stay at the Limestone
Correctional Facility until his oxygen saturation was lower than 80%.
There are signed statements in this patient's medical records by medically untrained officers.
These statements indicate that the officers were uncomfortable transporting the patient in
extremis. The officers were medically untrained. However, the officers were still able to
recognize that he was critically ill. The nurses at Limestone did not recognize that this patient
was critically ill or the nurses did not care and neglectfully chose to send the patient in the van
despite the officers’ verbal concerns. Instead, the patient was transported in the van by the two
officers and went into cardiac arrest and died with no medical personal present.
This is a clear example of the grossest neglect and inappropriate care provided to this patient.
The nursing staff should have recognized that the patient should be transferred emergently in an
ambulance with trained paramedics to the nearest hospital. He should not have been transported
to a hospital as distant as one in Birmingham.
This death could have been avoided. The patient’s diagnosis is unclear from the medical records.
A diagnosis of metastatic carcinoma was made by CT scan; not from a biopsy. This patient may
have had a very treatable infection, such as a fungal infection of the lungs, or even tuberculosis.
At any rate, Terrell Gray was permitted to die. This case demonstrates the lack of even a minimal
level of medical care and the substandard nursing care at the Limestone Correctional Facility.
58
DEATH SUMMARY
Chelsea Hammac
Chelsea Hammac was a 34-year-old male who died at the Limestone Correctional Facility on
11/14/2002 at 3:25 a.m.
This patient had advanced AIDS, as well as multiple complications, including CMV, retinitis,
wasting syndrome, herpes and candidal mouth infections, and chronic renal failure. Ultimately,
he most likely died from Pneumocystis carinii pneumonia (PCP).
Of note, the patient did have a rather extensive history of noncompliance. His antiretroviral
medications were reviewed multiple times by Dr. Simon, and the patient appeared to not want to
go back on therapy, although he had been on antiretrovirals in past. In fact, the patient had done
rather well in the past, but had been changed to a different regimen which caused nausea. It is
assumed, but not delineated in the medical records, that the patient ceased his medication
regimen because of their side effects. In none of the notes was the reason for the patient’s
refusal to take the antiretroviral therapy discussed with the patient. This was in spite of the
patient having very advanced AIDS and severe HIV complications.
In the end, the patient did decide to start antiretroviral therapy.
Of note, it appears that the patient also did not take his PCP or MAC prophylaxis. Again, the
reasons were not included in the medical record.
IMPRESSION:
The major issue in the patient’s case was that he appeared to be followed appropriately, but was
unable to take his medications. In particular, the medication to prevent the illness that ultimately
caused his demise (PCP), involved taking one tablet once a day or as little as three times weekly.
It is suspected that as the patient became more and more ill, as his energy level decreased, he was
unable or unwilling to stand in line for his medications. Medications at the Limestone facility are
dispensed to HIV-infected prisoners in a pill line. The prisoners stand in line outside of Dorm 16
-- in the heat of the summer or the cold of the winter -- to receive their medication sometimes up
to three times per day. A prisoner can wait up to one hour for their medication, which is difficult
or impossible for someone who is ill. There is not an attempt at Limestone to assist patients and
help them become more compliant.
59
DEATH SUMMARY
Eddie Harris
Eddie Harris was a 44-year-old male who was admitted to the Limestone Correctional Facility on
05/23/2000 and died one day later, 05/24/2000.
Mr. Harris had a history of AIDS. He had also been diagnosed with pulmonary Mycobacterium
kansasii, dementia, and AIDS wasting. His last T cell count had been 50. The patient had
previously been at the Montgomery County Jail where he had a rather extensive evaluation and
inpatient stay at the Baptist Medical Center. At that time he had been started on extensive
medications and treatments including INH, rifampin, ethambutol, AZT, 3TC, efavirenz and
Megace. All of these medications are appropriate.
Given that the patient was at the Limestone Correctional Facility for only one short day, there are
very few medical records available. The few records indicate that on 05/23/2000, the patient had
a fever of 102. He reported experiencing chills and shortness of breath. He expired the next day.
There is no further documentation addressing this patient.
IMPRESSION:
Given the short stay of this patient at the Limestone Correctional Facility, there are few medical
records. This was a very end-stage patient who appears to have been transferred on the
appropriate medications and who expired incredibly rapidly. It is unclear from the records why
the patient expired so rapidly at the Limestone Correctional Facility. This is concerning because
it is a pattern at Limestone Correctional Facility for HIV infected patients to expire rapidly.
Another concern is that there are no medication administration records in this patient's medical
record. Therefore, the patient may have never received his medication regimen as was intended.
60
DEATH SUMMARY
Kelvin Harris
Kelvin Harris was a 44-year-old male who died on 9/12/2001.
Conspicuously there is no information noted from the patient's chart from the year 2001, and
absolutely no information available surrounding the months prior to his death. As a result, this
review will focus on several other aspects of his chart and will not be able to focus on his death.
This is an AIDS patient who had a history of Pneumocystis carinii pneumonia and peripheral
neuropathy who had been on HIV therapies. The patient noted in 3/1998 that he was not being
given all three of his HIV medications. During that same month, in a physician note, the patient
was labeled as noncompliant. Approximately one month later, on 4/1/1998 a note by Ms. Riggs
(who was a nurse) stated “compliance of AZT and 3TC was only 50%.”
Guidelines were followed. It is difficult to read Dr. Moore’s notes because they are largely
ineligible which is typical of his notes, but the notes suggest that “by guidelines compliance is
less than 95% and the plan is to discontinue antiretroviral medications.” There was no discussion
of why the patient was unable to take his medications if he indeed was noncompliant, or if the
medications were not being supplied to him appropriately.
A health services request form from Mr. Harris pleads that he be restarted on his antiretroviral
medications. This demonstrates that the patient was motivated to restart his medications.
There is also a letter from the patient dated 3/5/1999. The letter is addressed to Mr. H. Dobbs of
the Health Care Unit. Mr. Harris writes:
“Mr Dobbs, I am having problems with the medication that I am presently taking,
which is D4T, DDI, and Crixivan. The problem that I am having is my feet and
hands are numb all the time and stay in pain. I am also throwing my food up;
can’t keep it down in my stomach. I am bringing this to your attention because I
don’t want to take myself off the medications. Maybe there is something that can
be done to help these side effects or possibly change the medications. Your
attention to this matter will be highly appreciated. Thank you. - Kelvin Harris”
At that time, it appeared that the patient was on a regimen that is very difficult to take consisting
of D4T, DDI, and Crixivan. Specifically, Crixivan needs to be taken on an empty stomach.
Crixivan causes a lot of side effects including abdominal pain and gastrointestinal (“GI”) upset.
D4T and DDI classically cause neuropathy. The patient described these side effects which we
see in patients on the same regimen.
At the bottom of this note, Dr. Moore callously writes: “Discontinue HIV treatment.” There is
actually discussion about trying to help the patient take these medications or treat his side effects.
61
The patient is seen several days later on 3/5/1999. He is complaining of nausea and vomiting
with pain in his feet. He was experiencing vomiting for several days. Dr. Moore did not perform
a neurologic examination, even though the patient was complaining of neuropathy. The
assessment is HIV positive since 1985. “Side effects: Neuropathy, nausea and vomiting.” The
treatment plan was to discontinue treatment for “drug holiday” (at patient's request). However, in
the note, the patient did not want to be taken off the medications. This note demonstrates that the
patient was not informed that the side effects could be treated and there were other medication
options for this patient.
Other notes in the chart describe the patient’s problems with these medications and not being
treated for side effects. The patient was eventually (six months later) started on a different
regimen. Again, the regimen was d4T, abacavir, and nelfinavir. Of note, nelfinavir causes severe,
horrible, watery diarrhea. Typically, treating physicians will immediately provide patients
medication to stop the diarrhea, including such simple things as Tums or antidiarrheal agents.
However, in this case, the patient was not administered any of antidiarrheal medication. In
addition, this patient had a history of neuropathy and was inappropriately started on a full-dose
of a medication (d4T) that appeared to cause his neuropathy in the past. This set the patient up
for failure.
IMPRESSION:
Although the cause of this patient’s death is unclear, and the medical records which would
provide information concerning the cause of death are absent, since no medical records at the
time of his death or for the year prior to his death were provided for review from the Department
of Corrections, this chart provides another important focus addressing the medical treatment at
Limestone.
The pattern that occurs over and over again at the Limestone Correctional Facility is one of
patients being started on therapies which might be appropriate, but they are set up for failure.
Patients at Limestone fail because they are not treated concurrently for known side effects, or are
given regimens that are nearly impossible to adhere too given the environment of the Limestone
Correctional Facility. In this case, it appears that this patient was started on a very difficult-toadhere-to regimen. In addition, the regimen caused rather significant and severe side effects. Yet,
even though these side effects can often be treated very easily by decreasing the dose of the D4T
for instance, or giving him medication for his GI upset from the Crixivan, instead Dr. Moore
chose to discontinue the medication and place the patient on a “drug holiday” which is not only
contraindicated in patients, but has been proven to lead to rapid deterioration.
62
DEATH SUMMARY
Michael Headon
Michael Headon was a 29 year old patient with class C3 AIDS who appears to have died on
09/18/2002, although I am unable to confirm because he died outside of the Limestone
Correctional Facility.
It appears that the patient was originally diagnosed with Pneumocystis carinii pneumonia at the
Huntsville Hospital. He was placed on antibiotics appropriately and was returned to the
Limestone prison system, and accepted for transfer on 09/13/2002.
The patient was admitted to the Health Care Unit and the initial nursing notes from 09/14/2002,
stated that the patient had “dyspnea” (shortness of breath) with an oxygen saturation of 81%
while on five liters of oxygen. This is critically low. The assessment was “altered respiratory
decreased oxygen saturation”. Despite the patient’s respiratory distress, the plan was to monitor
the patient's condition and administer antibiotics as ordered. Despite the patient’s grave
condition, Dr. Simon was not contacted, and the patient was only observed and continued to have
a low oxygen saturation.
Over the next few days, the patient continued to deteriorate. At one point, there was an oxygen
saturation recorded of 70% on 09/17/2002, while the patient was on large amounts of oxygen
supplementation. This is impending respiratory failure.
Mr. Headon was finally seen by Dr. Simon on 09/16/2002, and was prescribed an additional
antibiotic (Levaquin), given the concern that the patient most likely had a bilateral lobar
pneumonia or had acquired pneumonia while he was hospitalized. Unfortunately, this antibiotic
was not administered to the patient as ordered by the doctor. Consequently, his condition on
09/16/2002 was worse. He was breathing at 40 per minute while he was oxygen and IV Bactrim.
(Normal breathing rate is 12 times per minute.)
Most concerning was that the patient's oxygen saturation continued to deteriorate until and on
09/18/2002 at 12:00 p.m., one of the nurses wrote that “the patient is respiratory distress.” The
patient had been in respiratory distress for the past several days. “The patient has difficulty
breathing and his oxygenation is at 55%.” This is an extremely low oxygenation, and not
compatible with life.
IMPRESSION:
This patient essentially suffocated to death. His patient’s death demonstrates gross neglect
of a patient at Limestone Correctional Facility. This patient clearly deteriorated in front of the
nursing and medical staff at Limestone. His oxygenation was so poor that were he to have been
in a medical facility where appropriate care was administered, he would have been given
emergency ventilatory support (i.e. placed on a “breathing machine”).
63
Earlier on, it was discussed with the patient whether he wanted to have additional support (such
as being placed on a “breathing machine”), and Dr. Simon did write on 09/16/2002 that the
patient did NOT wish to sign a DNR (Do Not Resuscitate) form, which meant that the patient did
wish to have more invasive treatment. The patient’s wishes were not followed! The patient was
allowed to become ill beyond treatment, and he was admitted to Huntsville Hospital and expired
soon thereafter.
This patient was deathly ill and medications that were ordered were not administered. This is a
failing of the nursing and/or pharmacy system at Limestone. Medications written for must be
delivered to critically ill patients.
This case represents extremely negligent care of this patient. It is almost unbelievable that he was
allowed to basically suffocate to death.
64
DEATH SUMMARY
Dennis Hearns
Dennis Hearns was a 32-year-old male with C3 AIDS, cryptococcal meningitis, and AIDS
wasting. He expired at Limestone Correctional Facility on 06/04/1999 at 9:40 p.m.
A thorough review of the patient's medical records revealed that the patient had been HIV
infected for over one decade. The patient had been treated with multiple antiretroviral
medications in the past, and prior to his death, he had been on an antiretroviral regimen. The
review will focus on the patient's end-of-life care.
The patient was admitted into the inpatient unit at the Limestone Correctional Facility in
approximately February 1999. At that time, it was noted that the patient had AIDS wasting
syndrome. Wasting syndrome appears to be the cause of the patient's death. In reviewing the
patient's inpatient medical records at Limestone, it does not appear that the patient ever received
a thorough work-up for AIDS wasting syndrome. In addition, it is not clear from his chart
whether he received any appetite stimulants, which would have been an appropriate treatment for
his wasting syndrome.
In April, the patient was described as comatose. Yet, the medical staff decided that no further
treatment interventions would be administered; that the patient would be “kept comfortable”; and
that antiretroviral medications would be discontinued. For the next couple of months, the
medical record notes and the nursing notes indicate that the patient continued to decline. At one
point, the patient develops blindness. Again, the condition was merely accepted by the medical
staff. The patient’s blindness was not evaluated by the medical staff.
A review of the patient's laboratory results indicates that he did not receive any laboratory testing
after 3/30/1999 through his demise on 6/4/1999. No additional medical testing is evidenced in
his medical records.
The patient also reported hearing voices. On 5/17/1999, it was recorded that the patient did have
a history of psychiatric disease and had been on Mellaril (an antipsychotic). At that time, the
patient requested that he be put back on Mellaril, but apparently he was not put back on any
antipsychotic medications.
The nurses performed daily documentation of the patient's general status and occasionally
documented the vital signs. However, there is no indication of the patient’s weight or any
nutritional assessments of the patient that appears in the medical records.
65
IMPRESSIONS:
Mr. Hearns was a young 32-year-old AIDS patient who clearly had advanced AIDS. His
advanced AIDS condition was evidenced by a very low T-cell count as well as Cryptococcal
meningitis. In addition, he had quite severe wasting syndrome. Problematic in Mr. Hearns’
medical care is that he did not receive an appropriate or adequate work-up or treatment for AIDS
wasting syndrome. Simple medications can assist in stimulating a patient’s appetite or help this
patient gain life saving body mass. Due to this lack of treatment, the patient progressed to
advanced disease and died from AIDS and wasting syndrome.
An additional concern is that the patient became blind. Again, this condition was not evaluated
by the medical staff. There are many diseases, including cytomegalovirus (CMV), which can
cause blindness and are indeed treatable in AIDS patients.
As with other HIV infected patients at Limestone, Mr. Hearns did not receive adequate end-oflife care, much less adequate Hospice Care. There is no indication in the medical documents that
this patient requested such minimalist measures, or that he did not desire more aggressive types
of treatment for his disease. This is most worrisome. It appears that this Limestone medical staff
decided that the patient should not receive more aggressive treatment.
66
DEATH SUMMARY
Cletis Johnson
Cletis Johnson expired at the age of 36 on 05/24/2002 at 2:20 pm at Limestone Correctional
Facility.
To understand this patient's clinical course, one must briefly review the records from Kilby
Correctional Facility (the receiving center for incarcerated men into the Alabama Department of
Corrections), where the patient was initially incarcerated in the Alabama DOC. This patient
clearly had ongoing medical issues, including nausea and vomiting and malaise (just generally
not feeling well). While at Kilby, the patient received only minimal care.
Prior to the patient's transfer to Limestone, he was evaluated at Kilby by a registered nurse on
04/24/2002. At that time the patient was only on minimal medications. The intersystem transfer
form documents that the patient was stable and the nurse failed to check past chronic clinics,
specialty referrals, or significant medical history. In fact, in the medical records, after the
notation of significant medical history, there is a zero with a line through it, which signifies that
the patient had no significant medical history, notwithstanding that the patient indeed had
advanced AIDS.
The patient was transferred into the Limestone Correctional Facility with minimal history, as
well as inaccurately designated as having no significant medical history. When he arrived on
4/25/2002 at 2 p.m., the patient was not evaluated by the Limestone healthcare staff. Rather, he
was inappropriately evaluated by a correctional officer who designated in the medical records
that the patient appeared stable, which is hard to believe because only five days later the patient
filled out a health service request form, on 04/30/2003, and wrote in this form “feet have swollen
real bad and lots of thrush in mouth.” At any rate, correctional officers are not adequately
trained to make these types of decisions.
The patient’s medical request form was unfortunately not responded to until six days later, when
on 05/06/2002, Jay Cook, LPN, responded “will wait to see MD per patient.”
Mr. Johnson was not seen in the health care unit until 05/09/2002 at which time an attempt was
made to draw blood. He was not seen by a physician until 05/17/2002. At that time, Dr. Simon
documented that “the patient looks pale and ashy, has oral thrush, his skin is dry.” The patient
was immediately transferred to Huntsville Hospital.
On admission to the hospital, even though Dr. Simon indicated that the patient had no
complaints, the patient reported to the staff “can’t keep anything down. Weak and dizzy.” Dr.
Chassay, at Huntsville Hospital, performed a thorough evaluation and assessed the patient as
having nausea, vomiting a likely opportunistic infection, and esophagitis. It is clear from Dr.
Chassay’s evaluation that the patient, at the time of his transfer from Limestone, was very ill.
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Significantly, Dr. Chassay did elicit from the patient that he also had a 75-pound weight loss, and
in fact, he had not been on antiretroviral medications because he was told that they were not
available to him.
The patient was admitted to the Huntsville Hospital and was evaluated and was found to have
abscesses of the brain, which were most likely cerebral toxoplasmosis, a severe parasitic
infection. The patient also had severe esophageal candidiasis (yeast in the throat), metabolic
disturbances, as well as seizures from the severe brain infection that was thought to be
toxoplasmosis. After several days and hydration and some therapy, the patient continued to be
quite ill. Indeed, he required a large amount of oxygen because his oxygenation was so poor.
A call was made to Dr. Simon and the patient, despite being critically ill, was transferred back to
the Limestone Correctional Facility. At the Limestone Correctional Facility, the patient was not
treated for toxoplasmosis of the brain. He was admitted to the inpatient unit and was only
continued on treatment for his thrush as well as given IV fluids. He was also given oxygen. At no
time were antiretroviral medications initiated, despite the patient having only two T cells.
The nurses did evaluate the patient at least approximately every two hours until about 2:30 a.m.
on 05/24/2002. There is no documentation indicating that the patient was seen by any medical
personnel after 2:30 a.m. on 5/24/2002. The nurses note that the patient was rather ill, his skin
was dry and cool, and that the patient had “copious amounts of yellowish-white discharge
coming from his mouth and nares.”
The patient had an opportunistic infection (toxoplasmosis of the brain), as well as severe
respiratory distress. He expired on 05/24/2002 at 2:20 p.m. It bears mention that, it was Officer
Danny Albertson who found the patient dead and notified the medical staff. There is no
indication that any medical staff had treated or assessed the patient during the 12 hour period
from 2:30 a.m. through 2:20 p.m.
Mr. Johnson died one day after being discharged from the Huntsville Hospital, and the patient
died of a very treatable illness for which he was not being treated.
IMPRESSION:
This patient was an advanced patient with AIDS whose substandard care displays the profound
problems that occur when a patient is not evaluated and treated in a timely fashion and not
treated appropriate manner. Clearly this patient’s situation was advanced in both his AIDS
diagnosis, as well as the toxoplasmosis of the brain. However, toxoplasmosis is treatable, and the
patient was not treated for this illness. It is my opinion, within a reasonable degree of medical
certainty that the patient died unnecessarily and from a treatable illness. Contributing to this
patient's death was clearly the slow response of the medical staff to evaluate this very ill patient,
as well as the acceptance of a patient from a hospital facility back to a prison that was not able to
take proper care of a patient in an extremis condition.
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DEATH SUMMARY
Leslie Johnson
Leslie Johnson was 45-years old when he died in the Limestone Healthcare Unit, cell #153, on
12/04/1999 at 3:05 a.m.
The patient was HIV positive with a T-cell count of approximately 100. It was also noted that he
had liver disease. The medical records do not indicate whether the cause of the liver disease was
ever determined. The patient ultimately died on 12/04/1999 when he was found to have a weak
pulse and exhibited Cheyne-Stokes breathing.
The patient had an extensive discussion about end-of-life care issues with Dr. Khouri on
11/11/1999. According to this entry, the patient did not want any unnecessary prolonging of his
life. The note in his chart outlines the future disease process that the patient might expect. The
patient agreed and signed a “do not resuscitate” (“DNR”) order. This order was signed on
11/11/1999.
Soon after this patient signed this DNR order, the patient continued to decline in health. On
11/27/1999, the patient was noted to have a hematocrit of 15 (less than ½ normal), a prothrombin
time of greater than 15 (indicating severe ‘thinning of the blood’), and an extremely low platelet
count of 22,000. The question was raised about whether he needed a blood transfer; although
apparently the Athens Hospital does not release blood. It was believed that the patient should
receive blood from another hospital in Birmingham.
During the time, it was noted that the patient was not in distress, he was out in the yard, and that
a blood transfusion was not to be administered.
A review of the patient's additional laboratory tests on that day revealed that the patient had a
bicarbonate of 11, indicating that he was in rather severe acidosis (possibly an underlying
infection), as well as a glucose of 49 (normal glucose levels are greater than 100).
IMPRESSIONS:
Mr. Johnson was a 45-year old HIV positive patient with probable underlying chronic hepatitis
C. His chart does not clearly document the condition. This is inappropriate. Any patient with
underlying hepatitis or liver disease should have a diagnosis, or at least an attempt at making a
diagnosis recorded in their chart.
On 11/27/1999, the patient had some laboratory tests drawn indicating that the patient was very
severely ill. In fact, regardless of his symptoms, he was gravely ill. A bicarbonate of 11
demonstrates that the patient had a severe underlying acidosis and likely a severe infection. His
laboratory tests indicated that he had profound anemia and thrombocytopenia (low platelets) and
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a severe coagulopathy (thinning of the blood). Such a condition may very well result in a patient
bleeding internally.
The patient was not provided any treatment intervention. In fact, no attempt was made to reverse
his severe blood thinning (coagulopathy) or anemia. The patient died soon after these laboratory
tests were drawn.
While it was clear the patient had fairly advanced liver disease and agreed not to have life
extending measures, such as intubation or cardiopulmonary resuscitation (CPR), the lack of
adequate medical care was inappropriate and led to this death.
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DEATH SUMMARY
Morris Johnson
Morris Johnson was a 30-year-old male who died on 7/25/1999 at the Limestone Correctional
Facility. The incident report incorrectly dated the patient's death as 7/24/1999.
The patient carried a diagnosis of AIDS, chronic obstructive pulmonary disease, chronic
bronchitis, asthma and renal insufficiency (kidney dysfunction).
This review will focus on the events that led to this patient's death.
Beginning in 5/1999, the patient was seen in clinic by Dr. Khouri. The patient was complaining
of difficulty breathing. In fact, Dr. Khouri quoted the patient as stating, “Couldn’t breathe.” The
patient was placed on Corticosteroids (Prednisone), but returned approximately three weeks
later, on 6/14/1999, stating that he “can’t handle it in the dorm.” Dr. Khouri noted that the patient
was having great difficulty breathing. Dr. Khouri also noted that the patient had a high viral load
of 108,000.
At this time, the plan was to continue the patient on his current therapy and start him on the
antibiotic erythromycin. During the next several days, the notes in the chart, including on
06/15/1999 and 06/16/1999, clearly show that the patient was not doing well. In fact, on
06/15/1999, Dr. Khouri wrote that the “patient is HIV positive with end-stage AIDS and? PCP”
(abbreviation for Pneumocystis carinii pneumonia). The patient was on erythromycin which is
not effective against Pneumocystis carinii pneumonia.
On 6/22/1999, the patient continued to have shortness of breath and was desaturating. This
means that the patient was unable to breathe enough oxygen and was suffocating to death.
Previous patient records at Limestone Correctional Facility have indicated a similar desaturating
condition. The patient was taking clindamycin and erythromycin. These are two antibiotics
which do not specifically treat Pneumocystis carinii pneumonia.
The patient was still short of breath. On 6/24/1999, he reported that “the oxygen helps a little.”
On 6/25/1999, the patient was started on a subtherapeutic dose of Bactrim (even in the setting of
renal insufficiency), which was one double strength tablet b.i.d. times 10 days.
The notes in the chart for the next several days report that the patient continued to worsen. The
patient had a sulfa allergy and he had another allergic reaction to the Bactrim.
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Chest x-rays were obtained on 6/15/1999. These X-rays clearly demonstrated that the results
were consistent with Pneumocystis carinii pneumonia. Another chest x-ray on 7/1/1999 showed
results that were again consistent with Pneumocystis carinii pneumonia. A repeat chest x-ray on
7/15/1999 showed the same results. Given his initials on the reports, these chest x-rays were
viewed by Dr. Khouri. However, no action was taken by the Limestone medical staff.
On 7/21/1999, a pulmonary culture was obtained which showed the growth of a very resistant
and deadly organism called Pseudomonas aeruginosa. The patient was not initiated on an
antibiotic to fight this organism and on 7/23/1999 the culture results from blood obtained on
7/21/1999 confirmed the same results. Mr. Johnson died 4 days later on July 25, 1999.
IMPRESSIONS:
Morris Johnson likely died from PCP and a secondary deadly bacterial pneumonia which could
have been prevented if he had received appropriate therapy. This an example of another patient
at Limestone Correctional Facility who presented with a life threatening illness, was not
appropriately evaluated, was treated with a subtherapeutic dose of a medication and then died.
In addition, this patient became infected with a secondary bacterial pneumonia -- Pseudomonas
aeruginosa. Despite his rapid deterioration, he was not started on a life-saving antibiotic.
The treatment mismanagement of this AIDS patient demonstrates Limestone’s medical staff’s
lack of knowledge in even basic HIV management. Dosages of antibiotics are easily found in
simple texts, online, or can be obtained by calling the pharmacist.
72
DEATH SUMMARY
Stanley Lillie
Stanley Lillie was a 47-year-old male who died on Christmas Eve, 12/24/2001 at 7 p.m. at the
Huntsville Hospital.
There is no Huntsville Hospital report and no autopsy available.
The patient had a diagnosis of AIDS with a T cell count of less than 20 and a viral load of 98,000
obtained on 11/1/2001. The patient was also diagnosed with hypertension and a lupus
anticoagulant which caused him to experience recurrent deep venous thrombosis as well as a
history of pulmonary emboli. As a result of this condition, the patient had a filter placed and had
been on chronic high-dose Coumadin.
The patient was transferred from the Kilby Correctional Facility to the Limestone Correctional
Facility on 10/03/2001. At the time of his transfer from Kilby, the patient was on Bactrim,
azithromycin, low-dose Coumadin at 2.5 mg, and Maxzide.
On 10/08/2001, the patient sent a health care request form to the medical staff requesting a
bottom bunk. He stated that he had a blood clot in his lower extremity. This was answered by
LPN Kirk who responded that the patient would see the physician in “a couple of weeks.” The
LPN did not understand that this patient, who was on Coumadin, should have been seen by the
physician much earlier.
According to the medical records, the patient was not seen until at least 11/13/2001, six weeks
after his transfer to the Limestone Correctional Facility where he was admitted into the infirmary
with a swollen lower extremity. The concern was that he might have a clot in the lower
extremity. In response, he was administered a higher dose of Coumadin in addition to
subcutaneous heparin. However, he was not started on intravenous heparin. Because the
physician was ruling out deep venous thrombosis in the setting of Coumadin treatment,
intravenous heparin would have been the standard of care. Also, at this time he was not evaluated
for a lower extremity deep venous thrombosis.
The patient was seen on 11/18/2001 and was found to have “difficult veins.” It appears that a
blood draw was not done. In fact, the first blood draw that can be found the patient’s medical
chart is on 11/20/2001. On 11/19/2001 an attempt at a blood draw was also unsuccessful. On
11/21/2001 the PA-C wrote that the patient “needs a blood draw as soon as possible.” Multiple
attempts were made, but none were successful. The patient was not sent to the local hospital.
There was no attempt to obtain blood through a large vessel, which is the standard procedure.
On 11/26/2001, the patient reported bleeding from his rectum. His anticoagulants were then held.
The patient finally had a blood draw and the anticoagulation factor called PT-INR was normal.
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On 11/27/2001, the heparin was resumed. On 12/28/2001, the patient complained of fever and
chills with a temperature of 101.8. For some reason he was diagnosed with a viral syndrome by
the physician’s assistant. No blood cultures were drawn. The patient was not seen until
12/10/2001 when he was in acute renal failure. At one point, his creatinine increased to 3.9
(which is more than three times normal). He was sent to the Huntsville Hospital where he was
placed on intravenous antibiotics and then returned to the Limestone Correctional Facility.
The patient returned to the Limestone Correctional Facility and on 12/11/2001 he continued to
have a fever of 104 degrees. The physician notes that “the patient is an apparently healthy male
in no respiratory distress.” No medications were started. On 12/13/2001 the patient continued to
have fever of 103 degrees. Empiric antibiotics were appropriately started.
The patient's blood draw from 12/12/2001 showed that he had a blood stream infection with
coagulase negative Staphylococcus. On 12/17/2001 the physician noted that the patient received
his vancomycin on 12/15/2001 and then they ran out. Because they ran out of vancomycin, the
patient was placed on a different antibiotic on 12/16/2001 which in fact was not appropriate for
treating coagulase negative Staphylococcus. The vancomycin was resumed on 12/17/2001
because “a supply came in today.” The patient was also started on empiric antibiotics for another
infection.
The patient continued to experience fevers and he continued to decline. A blood draw from
12/20/2001 showed that he was neutropenic with a neutrophil count of 576, INR quite high at
6.4, a very high glucose of 542. In particular, the low neutrophil count was not addressed. The
patient was not put on G-CSF. He continued to decline.
The results of a blood draw on Christmas Eve, 12/24/2001, are present in the medical records.
The patient had a PT of 72.8 (extremely high) indicating a severe coagulopathy (thinning of the
blood). He was sent out to the Huntsville Hospital and died that night.
IMPRESSION:
This patient rapidly succumbed under the care of the nursing staff at Huntsville Hospital. The
patient had a long history of lupus anticoagulant, deep venous thrombosis and clotting which
caused him to have clotting factors abnormalities. It is apparent from the management of this
patient that he was not receiving appropriate or close enough monitoring of his anticoagulant
medications.
The patient developed an infection, probably of his blood, although the type of infection is not
known. He did have a severe coagulopathy (thinning of the blood) as evidenced by a very high
PT prior to his death. The patient was sent to the Huntsville Hospital and died quite rapidly. It is
not clear why the patient's low neutrophil count was not addressed nor why this patient was not
given closer monitoring of his anticoagulation medications.
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In addition, there was absolutely no discussion of antiretroviral therapy or starting this patient on
a regimen to help increase his CD4 count or his viral load. This patient could have benefited
from antiretroviral therapy.
The patient should have been evaluated much sooner. He appears to be yet another patient who
slipped through the cracks at the Limestone Correctional Facility because the medical staff was
overwhelmed.
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DEATH SUMMARY
Wilford Lockett
On 3/15/2000 at 2:15 p.m. Wilford Lockett was pronounced dead at the health care unit at the
Limestone Correctional Facility after having collapsed on the prison field while umpiring a
softball game.
Mr. Lockett was a 68-year-old male with HIV infection, questionable seizure disorder,
hypercholesterolemia, and hypertension. The patient received an external autopsy -- as did all
HIV infected patients -- which is uninformative. In fact, the autopsy lists the patient's illnesses
incorrectly. He is listed as having human diabetes (human diabetes is not a known medical term)
and hypocholesterolemia (low cholesterol) as opposed to hypercholesterolemia (high
cholesterol).
The patient was originally seen at the Kilby Correctional Facility and complained of left-sided
pain. At that time, he was given Motrin and was found as having a high blood pressure at
144/102 (normal is less than 120/80). He was also found to have a high blood sugar of 375 (four
times the normal range).
A review of the patient's medical records at Kilby also indicate that he had an extremely high
glucose of 698. Nothing was done to address this condition because the patient arrived at the
Limestone Correctional Facility on 2/19/2000 and the transfer form from Kilby did not list the
patient on any medications and listed his only medical illness as being HIV infection.
Specifically diabetes, hypertension, hypercholesterolemia, and seizure disorder were not listed as
medical illnesses.
At the Limestone Correctional Facility, a third serum glucose was obtained and measured 232.
This is more than twice the normal range. The patient also had a high cholesterol of 214. He was
seen almost three weeks later by Dr. Khouri who reported that the patient had “high blood
pressure. Rx Norvasc - 3 years.” The next line states “diabetes - no meds.” Dr. Khouri’s
assessment was “ ? diabetic, ? hypertension” This demonstrates that Dr. Khouri had not reviewed
this patient’s chart, much less obtained an adequate medical history.
Despite the fact that the patient had three high blood glucose results, no medications were
initiated. These tests clearly indicated that the patient was a diabetic and hypertensive. The
patient was not seen again until he collapsed out in the yard. An unsuccessful attempt was made
to resuscitate the patient. However, it appears that he died of cardiac arrest.
IMPRESSIONS:
Wilford Lockett was an elderly patient with multiple medical problems. He was at a very high
risk for cardiac disease. The medical staff at Limestone Correctional Facility and Kilby, did not
heed this patient's symptoms or his laboratory values and did not treat his underlying diabetes,
hypertension or hypercholesterolemia. This patient clearly died of a cardiac arrest which could
have been thwarted had he been treated appropriately.
76
It is unclear why these very obvious laboratory values were not treated, and why the patient's
underlying illnesses were not treated. This is an example of a pattern at Limestone and Kilby
where laboratory tests are drawn and the patients suffers because they are not treated.
This HIV-infected patient appears to have died from a cause unrelated to HIV, concerns about
care at Limestone for patients with other serious diseases such as diabetes, coronary artery
disease and hypertension must be brought into question.
77
DEATH SUMMARY
Joseph McClure
Joseph McClure was a 71-year-old male who died on 05/06/2002. The patient's medical records
are incomplete. There are no medical records after 03/30/2002. This is a full five weeks prior to
the patient's death.
Mr. McClure had the diagnosis of AIDS with a low T cell count of 28; he was originally
diagnosed at the Kilby Correctional Facility. The patient also had diabetes mellitus and
hypertension, renal failure, and benign prostatic hypertrophy. Additionally, the patient also
suffered from severe anemia.
It is important to review the patient's medical records from Kilby Correctional Facility which
showed the patient had a T cell count of 32, a viral load of 75,300 and a creatinine of 3.7 (a
normal creatinine level is less than 1.4). The blood test was obtained on 08/03/2001.
While at Kilby, this patient’s renal failure was never evaluated. The patient was placed on
medication to treat his hypertension and diabetes. However, the patient went into a
hypoglycemic coma. Soon thereafter the patient was transferred to the Limestone Correctional
Facility on 10/03/2001.
On 10/08/2001, the patient was seen by Dr. Simon. Dr. Simon started the patient on an
antiretroviral regimen. Yet, at Kilby, the patient had inappropriately not been placed on MAC
prophylaxis. So, MAC prophylaxis was started. He was continued on Pneumocystis carinii
pneumonia prophylaxis, as well as his other multiple medications.
The patient complained of difficulty urinating as evidenced by a health services request form as
early as 10/28/2001 which stated “I’m having problems urinating; at times I can’t urinate.” The
nursing staff’s response to this is that the patient “seen MD on 10/18/2001.” The nurse did not
even address the patient's’ problems of urinary retention.
Despite the patient's complaints and evidence of renal failure, he did not get an initial evaluation
for his renal failure until February 2002. At that time, the patient was seen in consultation by a
urologist who obtained a renal ultrasound which showed that the renal pelvises and ureters of the
kidneys were very large. The condition is concerning because it can cause obstruction from his
enlarged prostate. The Limestone Correctional Facility obtained a laboratory test on 03/27/2002
indicating a BUN of 91 (which is approximately four times the normal level) and a creatinine of
8.3, which demonstrated that the patient was in almost total renal shutdown. His potassium was
also critically high at 6.4. His hematocrit was 13 which was about one-third of normal. His
bicarbonate was 10, also demonstrating that the patient had very severely impaired renal
function. Attempts were made to lower the patient's potassium.
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At the point, there are no further medical records. This absence of medical records is very
concerning.
IMPRESSION:
This patient was an elderly and fragile gentleman who clearly had evidence of an obstruction in
his urinary tract secondary to an enlarged prostate. As early as August 2001, the patient had very
severe kidney function problems. It was not until a full six months later, when the patient was at
the Limestone Correctional Facility, that he received an evaluation for this kidney failure. By
that time, it was too late. The patient's kidneys shut-down.
There are also missing records from this patient's chart. It is unclear what caused this patient’s
death. Yet, it is most likely that Mr. McClure died from the renal failure with complications
caused by the HIV infection, diabetes mellitus and hypertension.
There is a pattern that occurs over and over again at the Limestone Correctional Facility where
patients who are extremely ill, are examined, evaluated and laboratory tests are sometimes
obtained with no follow-up, no work-up, and no further evaluation when warranted. Sometimes
these results, such as a creatinine of 3.7, as was the case in this patient, which demonstrates that
the patient needed an evaluation of his kidney function, are not evaluated, and the patient
progresses to a severe worsening of his disease.
Additionally, this patient had a very low T cell count and should have been transferred to
Limestone on Mycobacterium avium complex prophylaxis which consisted of azithromycin.
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DEATH SUMMARY
George McHeard
George McHeard was a 48 year old patient who died on 11/12/2001 at 12:15 a.m. at the
Limestone Correctional Facility. This patient was HIV positive and had noninsulin-dependent
diabetes mellitus which was poorly controlled. He also had hypertension and
hypercholesterolemia, as well as a seizure disorder.
On 11/11/2001, the patient presented to the Health Care Unit complaining of abdominal pain,
vomiting, and headache, but no fever or diarrhea or other symptoms suggestive of a viral illness.
The patient was also complaining of chest pain, as this was documented in the nursing notes of
11/11/2001 at around 10 p.m. When the patient reported that “my chest and stomach is hurting; I
feel weak and trembling and am throwing up,” the patient was given some IV fluids and
medication. The patient continued to be ill throughout the evening. He continued to have
abdominal pain and appeared to be rather sick.
At 10:30 p.m., the patient was moaning and groaning, moving from side to side, with labored
respirations. He was breathing at 24 per minute, which is fairly rapid. Obviously the patient was
in a significant degree of pain. Again, he continued to have increased pain at 11 p.m. By 11:30
p.m., the patient had no complaints and appeared sleepy. He was assessed at least a couple of
times by the nurses. He was then found, at least initially, by the inmates to be pulseless and dead.
IMPRESSIONS:
This is a diabetic who had multiple risk factors for having a heart attack, yet he was not
evaluated for this condition. His medical records contain no reference to an EKG. Nurses as
Limestone are unaware of different presentations of heart attacks and patients die needlessly.
This patient most likely died of a myocardial infarction (a heart attack), but that cannot be
ascertained with any degree of certainty. After the inmates placed the patient's body in a body
bag, which is standard procedure at Limestone Correctional Facility, the inmate did undergo an
autopsy which really consisted of a visual autopsy. There was no organ inspection or evaluation
of the patient's coronary arteries. Of note, only VISUAL autopsies are performed in the
Alabama correctional system.
This inmate, who had diabetes, presented with almost classic angina or chest pain for a diabetic;
yet the patient was not evaluated for this condition. It is assumed that he had an ongoing heart
attack and died as a result. The patient was not properly evaluated.
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DEATH SUMMARY
James Pryor
James Pryor was a 36-year-old male who died on 10/13/2001 from cryptococcal meningitis
secondary to AIDS. The patient had only recently been diagnosed as HIV positive at the Kilby
Intake Correctional Facility. He was diagnosed as HIV positive on 9/26/2001. The patient was
transferred to the Limestone Correctional Facility on 10/4/2001.
Upon being received by the Limestone Correctional Facility, the patient complained of fever,
chills, dizzy spells and headache. He stated that “I’m not feeling good.” He was noted to have a
very high pulse and to be ill. He was immediately sent to the Athens Hospital and given a
presumptive diagnosis of bacterial pneumonia versus Pneumocystis carinii pneumonia.
The patient was transferred back to the Limestone Correctional Facility on 10/7/2001 and seen
by Dr. Simon. Dr. Simon appropriately administered tests for toxoplasmosis and cryptococcal
meningitis titers. The cryptococcal meningitis titer returned extremely high at 1:4096 which
indicated that he had very severe cryptococcal meningitis.
Dr. Simon immediately sent the patient back to the hospital for further management of his severe
cryptococcal meningitis and also ventilatory support because he had such severe respiratory
symptoms. Unfortunately, the patient died soon thereafter on 10/13/2001, after it had been
decided by his family, given his advanced cryptococcal meningitis, that they would not pursue
any further life-saving measures.
It was also noted that he had a T cell count of 35 and his viral load was 26,000 at the time of his
death.
IMPRESSIONS:
This is an example of another patient in the Alabama correctional system who was very unstable
and was inappropriately transported from the Kilby Intake Facility to Limestone. This clearly
demonstrates that there is little or no communication between the Kilby Correctional Facility and
the Limestone Correctional Facility because it is doubtful that any reasonable medical personnel
would have accepted this patient given that he was recently diagnosed HIV positive and had such
severe complaints. Instead, the patient should have been immediately sent to a hospital.
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DEATH SUMMARY
Willie Robinson
Willie Robinson was a 48-year-old male with AIDS and a T cell count of 20 in 9/2000. He died
on 11/5/2002 in the health care unit at the Limestone Correctional Facility, although there is little
documentation. The patient has a history of HIV infection, but no confirmed opportunistic
infections.
On 8/29/2002, the physician noted in the chart that “the officer reported that patient has been
looking disoriented lately.” The patient reported that he had experienced fever for two days and
was feeling lazy and tired. The physician reported that the patient was on Bactrim, which “he
does not take regularly.” The note further indicates that the patient is a chronically ill-looking
male. There was no mention of discussion with the patient addressing why he was not taking his
medications, nor was there a neurologic exam documented. Minimal labs were done. On
9/3/2002, a toxoplasmosis titer was negative and a Cryptococcal antigen was also negative.
By this time, the patient had been in the health care unit for four days. He was then released from
the health care unit. He was seen on 9/11/2002, by the physician. At that time, he was
complaining of poor appetite. The physician noted in the chart that the patient was a wasted
looking male. The physician’s diagnosis was wasting. Antiretroviral therapy was started. There
was no mention of even a discussion of starting the patient on any type of appetite stimulant or
any kind of medications to increase his critical body mass.
On 10/16/2002, the patient was complaining of being fairly sick and of throwing up. He reported
that he thought he needed more food to take with his medications. The patient was not offered
any more food. However, he was given some oral supplementation. On 10/22/2002, the patient
complained of an upset stomach with his medications.
On 10/31/2002, the patient was seen by the physician and reported that he had been becoming
confused. There were multiple nurse’s notes that the patient had been in fact getting confused.
The diagnosis at this time was HIV dementia, although no head CT was done -- only a minimal
work-up consisting of toxoplasmosis and Cryptococcal antigen tests.
On 11/01/2002, the patient had an unsteady gait. Before the patient's death, the toxoplasmosis
titer came back positive. He was started on medications for toxoplasmosis, and he died the next
day of an unknown cause.
IMPRESSIONS:
Mr. Robinson’s case represents another instance of a Limestone patient who had advanced AIDS
and proceeds to a rapid death from most likely a preventable, opportunistic infection. This
patient was clearly lost in the medical system and a follow-up should have addressed prevention
for opportunistic infections. While it is clear that any patient can refuse a medication, it is
incumbent upon the medical staff to make medications easily available to patients and to explain
to the patients in a thorough manner why it is important for them to take these medications.
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There were multiple times when this patient missed his medications and it can be assumed that
this may have been because he was unable to stand in the long pill line, as evidenced by the
reports of the patient looking wasted, disoriented, and confused, and even unable to walk or
having an unsteady gait. He was unable to take his medications and was not monitored.
A review of the medical records are of further concern because the patient clearly had a mental
process (a neurologic defect) occurring for quite a while. Yet, no imaging studies were
conducted of his brain. It is very important for the medical staff to at least have done a scan of
the patient's brain to evaluate for a central nervous system process.
As is the case with many patients who have died, this patient also had severe AIDS wasting. It is
concerning that these patients are not getting enough calories. This patient reported not getting
enough food to eat. Although he was not supplemented with any more food, he was given oral
supplementation. It is clear that patients who are very, very ill and have AIDS, have high caloric
needs (sometimes twice the normal level) and if their needs are not met, they ultimately die of
starvation. It is concerning that these patients at Limestone are in fact dying of starvation given
that they are not receiving adequate nutrition, much less do not have access to a nutritionist.
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DEATH SUMMARY
Tony Rowland
Tony Rowland was a 30 year-old male who died on 01/22/1999 at 7:00 a.m. at the Limestone
Correctional Facility health care unit.
Mr. Rowland had end-stage AIDS, polyarteritis nodosa, end-stage renal failure, AIDS wasting,
and cardiac arrhythmias. Again, I will focus mainly on the patient's lack of end-of-life care on
this summary. The patient was admitted to the inpatient infirmary on 12/28/1998 after it had
been noticed at least a week prior that he had had fevers up to 104 degrees F. At that time, it was
noted that the patient had a bacterial pneumonia and he was placed on oral antibiotics.
Throughout the inpatient stay, however, the patient's course was one of continued decline. The
documentation of his treatment was extremely poor. Very few notes were written by the
physician. The notes that were written by him are extremely difficult to read or are not
informative.
It is clear from the medical record that the patient was admitted to the inpatient infirmary and he
continued to have fevers. However, his fevers were not evaluated appropriately. The patient died
in the inpatient unit.
Of note, on review of the patient's medication administration record, he was not on any
Pneumocystis carinii pneumonia prophylaxis and was not on any prophylaxis for
Mycobacterium avium complex. These medications would be indicated given his low T cell
count (on 08/1998) of 25 and a high viral load of 295,000. It is clearly the standard of care to
place patients on prophylaxis for these infections, especially if they are on an inpatient unit.
On 04/16/1998, there was a very worrisome note by a licensed practical nurse (LPN) who
advised the patient of his “poor compliance with antiretroviral therapy.” This LPN “advised the
patient that therapy would be discontinued secondary to his poor compliance.” The LPN goes on
to list that two of medications he is “34% compliant with” and one of his medications he is “52%
compliant with.” Unfortunately, there was no discussion with the patient as to why he was not
being compliant. He was not asked if he was having any side effects. He was not educated on
the importance of adherence. Given the patient's advanced illness, it was unclear whether the
patient was even capable of standing in the pill line to obtain his medications. The patient
became upset during this medical visit.
I was unable to find any DNR (Do Not Resuscitate) orders, no advanced directive, and no
discussion of how aggressive the patient wished therapy to be undertaken. It appears that this
was decided by the medical staff at the facility.
IMPRESSIONS:
This is yet another example of a patient at the Limestone Correctional Facility who had a rapid
decline in his HIV status. His condition was extremely advanced and he had complications that
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included kidney failure. There was very little documentation provided, but I was unable to find
any evaluation of his kidney failure, much less any treatment for this. Unsurprisingly, the patient
died rather rapidly of infection.
Also, it is concerning that there was no discussion regarding end-of-life care, advanced directive,
or DNR status of this patient.
The staff at the Limestone Correctional Facility seemed very quick to take medications away
from patients if there were “noncompliant.” It should be the role of the physician, not an LPN,
to assess patients and decide if a prescription should be discontinued. The medical staff does not
seem to understand the importance of a good therapeutic relationship or the value of discussing
compliance issues with patients. The appropriate questions were not asked: was he able to obtain
his medications, was he able to stand in line, was he having any side effects, or were other
therapies necessary? These questions should have been asked by an physician. LPN’s at
Limestone are routinely practicing outside the scope of their licenses.
Another issue of concern when treating a patient with such advanced AIDS, is whether the
patient was depressed. Depression was never discussed with this patient. This further shows the
lack of care that is provided to the patients at the Limestone Correctional Facility.
Inexpensive and easy to offer medications, such as prophylaxis for Pneumocystis carinii
pneumonia and Mycobacterium avium complex, were not offered to this patient. He might have
died from one of these easily prevented infections.
This patient, as were many others, was labeled with end-stage AIDS. This term became a death
sentence for patients so labeled at Limestone Correctional Facility. It appears that the nursing
and medical staff at the facility do not perform any further interventions or evaluations on these
patients.
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DEATH SUMMARY
Dionicio Salazar
Dionicio Salazar was a 41 year old HIV positive male who died on 9/16/1999 at 3:42 p.m. at the
Limestone Correctional Facility health care unit.
This review will focus on the patient's last few days prior to his death. The patient had no prior
opportunistic infections, even though he was HIV infected and had a relatively low T cell count
earlier in the year of 159. These results were obtained in 1/1999.
In 11/1998, the patient had “refused HIV treatment” per Dr. Moore’s note despite treatment
being indicated. It is unclear whether the patient understood English well enough to comprehend
this refusal of HIV treatment. Just prior to Dr. Moore’s note, there is a nursing note that states
the following on 7/29/1998: “The inmate has a problem with communication, understanding
English language and speaking English language. This nurse tried to advise inmate of increased
viral load and decreased CD4 count and treatment with antiretrovirals ….” There was absolutely
no attempt at obtaining interpretive services.
The patient was not placed on any treatment for his HIV infection. The patient was transferred
from the Kilby Correctional Facility on Haldol and trazodone for an unspecified psychiatric
illness. These medications were for treating either depression and/or schizophrenia. It is
noteworthy that the patient did not have any clear evidence of uncontrolled psychiatric disease
and took all of his psychiatric medications while incarcerated at the Limestone Correctional
Facility and was quite compliant in that respect.
There are several handwritten notes by other inmates for the patient. He probably relayed
information regarding different complaints. It is clear from his record that he was unable to write
in English. It is evident that these were not his notes because the handwriting of the signature is
different from the handwriting which completed the health services request notes.
The patient’s severe decline in health appears to have started several days prior to his death as
evidenced on 9/7/1999 when he had a very large increase in his liver enzymes with a SGOT of
1248 (30 times normal) which signified that he had liver failure. He also had a creatinine at that
time of 2.7 (normal is less than 1.3) which signified that he had a loss of kidney function. He also
had abnormalities in his electrolytes.
The patient's liver abnormalities remained severe and his kidney function declined. The patient
was in the inpatient unit at the Limestone Correctional Facility. He was followed and
subsequently died of what appeared to be fulminant liver failure and kidney failure with a
bacterial pneumonia, possibly Pneumocystis carinii pneumonia. It was recognized that the
patient might have pneumonia. A chest x-ray had been obtained on 9/10/1999, six days prior to
his death. The patient was started on medication for presumptive Pneumocystis carinii
pneumonia and bacterial pneumonia at that time.
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The patient died after a rather rapid downhill course.
IMPRESSION:
This patient most likely died of liver disease in addition to kidney disease which was
complicated by HIV infection. There was actually no underlying cause of his liver disease. He
never received a thorough evaluation of his liver disease. The patient should have had an
evaluation by a liver specialist. However, this evaluation never occurred. This demonstrates a
pattern at the Limestone Correctional Facility where patients are not seen by specialists and are
instead evaluated by generalists or by others who are not adequately trained to deal with such
specialized fields of medicine.
In addition, this patient appears to have acquired possible Pneumocystis carinii pneumonia.
Although he refused HIV medications, it is unclear whether he refused any prophylaxis or
whether he understood the ramifications of refusing prophylaxis. In the end, he did not refuse
any of his other medications. This questions whether he understood the ramifications of his
decision.
Also, the patient had language barriers. There was no attempt at the Limestone Correctional
Facility to provide an interpreter for this patient to try to assist him in obtaining better medical
care.
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DEATH SUMMARY
Milton Smiley
Milton Smiley was a 43-year-old male who died on 2/12/2003 from complications of cirrhosis.
The patient had carried the diagnosis of AIDS with a T cell count of 118, hepatitis C with
secondary cirrhosis, low platelet count, AIDS wasting, osteonecrosis of his hips bilaterally,
chronic bleeding hemorrhoids, chronic nausea and vomiting.
Mr. Smiley’s medical records are extensive in that they demonstrate that he had multiple major
medical problems which resulted in his being seen in the infirmary on frequent occasions. The
most significant visits were for excessive bleeding. He had bleeding from his nose which needed
packing and also bleeding from a hemorrhoid in the rectal area. The rectal hemorrhoid bleeding
was exacerbated by the patient's difficult clotting secondary to cirrhosis and his low platelet
count. There is no documentation in the chart demonstrating that the patient was ever surgically
evaluated to stop the rectal bleeding, although it was a significant medical problem.
Another major issue for this patient involved chronic nausea and vomiting. These symptoms of
the patient's illness were not investigated. On 10/25/2002, one of the nurses accused the patient
of self-inducing his vomiting.
There are multiple entries in the chart where the patient experienced decreased mental status in
which he was “too groggy, too sedated, as well as unable to walk.” In all of these entries, there
was no further evaluation of this patient. In many of these instances, the patient was unable to
take his medications. When the patient was not in the health care unit, he was often unable to
stand in the pill line to obtain his medications. When he did not stand in the pill line, the nursing
staff did not administer the patient his medication.
On 10/1/2002, the nurse responded to a call that “Smiley fell.” It is not documented in the chart
that the nurse rendered assistance to the patient. No physician was called even though it is the
standard of care that a physician must be contacted and an evaluation conducted when a patient
in an inpatient unit falls.
The medical chart does not contain a death certificate or an autopsy. As with all of these patients,
the actual cause of death must be ascertained by review of all available medical records since no
post mortem autopsies are performed. Only external autopsies are performed on HIV infected
individuals. There is no “Do Not Resuscitate” order and no Advanced Directive for this patient.
There was also no discussion addressing end-of-life care for this patient. Mr. Smiley was
pronounced dead at 5:45 a.m. on 02/12/2003.
IMPRESSIONS:
1.
This is a patient with advanced cirrhosis from hepatitis C. The major manifestation of this
disease in this patient is rectal bleeding. The patient was never evaluated by a surgeon or
a gastroenterologist in an attempt to stop the bleeding. Yet, the bleeding created great
problems for the patient.
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2.
There were also numerous documentations that the patient experienced decreased mental
status when he was almost unable to stay awake. He was highly sedated and unable to
take his medications. A review of the patient’s medical records clearly demonstrates the
lack of care that he received by the nursing staff. For example, when the patient was not
in the inpatient unit, he would not be administered his medications by the nursing staff.
3.
The patient also experienced chronic nausea and vomiting which was not evaluated. This
condition was treated, but should have been further evaluated. Chronic nausea and
vomiting in an advanced AIDS patient must be taken seriously and such treatable and
deadly illnesses as lactic acidosis and pancreatitis must be part of an initial evaluation.
They can both be easily evaluated by a blood draw.
4.
In addition, as with most patients reviewed, there is no discussion of end-of-life care,
although it is reasonable that in a patient who is this ill, a “Do Not Resuscitate” order
should be instituted. It is an accepted medical standard that patients have this discussion
rather than the medical staff making these decisions for the patient.
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DEATH SUMMARY
Lamar Smith
Lamar Smith was a 49-year-old patient at the Limestone Correctional Facility who died on
01/21/2002.
The patient suffered from AIDS co-infected with hepatitis C and was on appropriate
antiretroviral therapy which consisted of Viracept, Zerit, and Ziagen. He was fairly stable,
although he did suffer from chronic anal herpes infections and rectal prolapse, until he was seen
initially on 01/15/2002 by the physician’s assistant, Ms. Ebbe. At that time, the patient had some
facial swelling as well as was noted to be jaundiced. At that time liver enzymes were obtained
which showed that the patient clearly had a severe hepatitis (inflammation of the liver) in that his
liver enzymes were very high. His AST was 542, ALT was 508, bilirubin was 7.5. Carbon
dioxide was 21.
The patient was seen the next day on 01/16/2002 and admitted to the health care unit. At that
time, it was noted that the right side of his face had further swelling, that his right eye was in fact
swollen shut, and that he had a distended abdomen. The patient was seen on 01/17/2002 by Dr.
Simon, and at that time, the patient was noted to be complaining of “tightness of the throat,” as
well as “difficulty swallowing.” The patient was given Benadryl without any improvement. He
continued to have throat tightness and difficulty swallowing.
The patient had some mild abdominal distention and a rash, and some mild desquamation – a
process where the outer layer of the skin falls off. It was thought that the patient had acute
hepatitis secondary to an allergic reaction to medications. He was followed in the Inpatient Unit,
but did not improve. According to the nurses’ notes, in fact, the patient not only did not improve,
but he continued to deteriorate and was having bouts of increasing confusion and difficulty
arousing him. In fact, on 01/20/2002, one day before the patient died, it was noted that the
patient at 6 p.m., was not moving and did not respond to command, only reflexes. He apparently
did not respond to painful stimuli. The patient was very ill at this time and very severely,
profoundly neurologically depressed. Suppression of the neurologic system was determined to be
the assessment.
Unfortunately, at that time no one was called, and the patient was assessed 3:30 a.m. on the
following day, January 21, 2002 and was found dead.
IMPRESSION:
It is my opinion within a reasonable degree of medical certainty, that this patient should have
been followed very closely in a hospitalized setting. Six days prior to his death, on January 15,
2002, this patient’s HIV was under fairly good control with a T-cell count of 439. He potentially
had a fairly long life span. It appears that this patient had a toxic hepatitis secondary to his
medications. He died of fulminant hepatic failure most likely as a result of his medications.
More attentive medical surveillance could have resulted in saving his life.
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Of note, in this patient (as with other patients), it appears as if inmates were asked to help
prepare the patient's body, as well as to place the patient in a body bag. This practice is
inappropriate.
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DEATH SUMMARY
Timothy Summers
Timothy Summers was a 32-year-old male with a history of AIDS, but no known opportunistic
infections. He had a low T cell count (less than 50) and he died at the Limestone Correctional
Facility on 3/11/2002.
The patient’s medical records, as is the case with many of the other medical records, demonstrate
multiple times that the patient was labeled as noncompliant with his medication regimens, and
multiple times in which the patient's medications were discontinued. However, nowhere in the
chart is there a discussion as to why the patient was unable to take his medications and no efforts
were made to help this patient become more compliant.
The patients at Limestone Correctional Facility are made to stand in a long pill line to take their
medications. Many of these patients are unable to stand in line or unable to understand the
importance of taking their medications.
This patient suffered from a chronic severe skin rash as evidenced by his multiple pleas for
assistance to the medical staff. There are many health service request forms from the patient
stating that he had a severe rash. At times the rash appeared to be even ulcerating and causing a
secondary bacterial infection.
The patient was initially received on 7/15/2001. By 7/25/2001 he was using health service
request forms to contact the staff that he was having blisters. On 11/27/2001, he reported that he
had bumps that “itches like mad, sores on face that hurt and don’t want to heal.” The nurse states
that the patient remains noncompliant with all medications. Yet, she does not attempt to discuss
noncompliance with the patient. The patient is concerned about noncompliance. He is also
concerned about another medical disorder that he is experiencing.
On 12/16/2001, the patient stated that he “needs for his records to be sent from the Kirkland
Clinic” and he requests an MRI given that he might have an aneurysm, although he does not
spell aneurysm correctly. It was clear from his note that he is referring to a brain aneurysm. He
spells it “anarivem of brain.” On 12/18/2001, in a health services request form, the patient
complains of chronic skin rash. He was seen by the physician who diagnosed the patient with
HIV dermatitis. The patient was not seen by a dermatologist. No biopsy was done. Although
there was no attempt to document a noncompliance discussion with the patient, the physician
reported that the patient was noncompliant and the patient “still does not want antiretrovirals.”
In the patient's chart, records arrive at some time from the outside hospital and these are
available for review. There is a clinic visit that states that the patient has a history of an
aneurysm. The source of this information is unclear, but the information is dated 7/16/1999.
There is also a brain CT result from 7/19/1999 which describes the following. Impression: 13mm left and 9 to 10-mm right prominently hyperdense masses just anterior-superior to the
internal carotid artery, supraclinoid segment bifurcations. It states “aneurysms are expected.”
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This patient’s condition is showing aneurysm, Dr. Simon writes “aneurysms” on the CT result
and initials it on 11/09/2001. Despite this result, the patient has no further work-up at the
Limestone Correctional Facility.
On the day of the patient's death, 3/11/2002 at 2 a.m., a nurse is called to the room by the inmate
stating, “he was having a seizure.” The nurse writes that upon entering the patient's room, the
patient is having severe tremors. His eyes rolled back into his head. He had no verbal response to
his questions. The nurse turned the patient’s head so that he will not aspirate. She took some vital
signs. The patient started to respond. Soon thereafter, the nurse left the room. At 2:25 a.m. the
nurse was called back to the room. The patient was seizing again. The patient was described as
being restless, moaning, rolling back and forth in the bed when his head rolled back and the
patient went rigid.
At that point Dr. Simon was notified and gave the patient Valium 10 mg IM at 2:33 a.m. At 3:15
a.m., the nurse left the room. The patient was having difficulty breathing. Respirations were
labored. He had Kussmaul breathing noted which was very worrisome. Respirations were
between 9 and 12 with periods of apnea lasting up to 30 seconds. Dr. Simon was notified at 3:25
a.m. and IV normal saline was started and the patient was given an antiepileptic drug called
Dilantin. During the procedure, the patient became cyanotic, cold and gray. Apparently his color
improved slightly. The patient remained unconscious without any verbal response. Prior to 4:45
a.m., the nurse again left the patient alone in the room.
At 4:45 a.m. the nurse returned to the patient's room. The patient’s respirations were uneven and
labored; they were 4 to 6 times per minute. Again, this patient was barely breathing. The patient
was moved to a private room and oxygen was administered. Upon moving, the patient stopped
breathing. Apparently cardiopulmonary resuscitation (CPR) was started at 5:15 a.m., but only
after a mere 10 minutes, CPR was stopped. There was absolutely no documentation as to what
was done as far as the CPR went; there was no advanced cardiac life support. At 5:30 a.m. on
3/11/2002, the inmate is pronounced dead by Dr. Simon. However, the note was signed by L.
Robertson, RN.
IMPRESSIONS:
This note, dated 3/11/2002, displays the almost incredible lack of insight by the medical and
nursing staff at the Limestone Correctional Facility into the seriousness of severe illness and how
these types of illnesses need to be handled. This patient had a grand mal seizure. He initially
showed signs of being quite ill. He had a history of having had aneurysms which were ignored
previous to this disastrous medical event. With the exception of one outside medical record, this
was not even documented in the patient's chart. The nurse was unaware of this medical history.
The nurse tended the patient, then left the room. She did care for him appropriately. This was a
patient who was severely ill and who should have received one-on-one patient care in a highly
skilled medical facility (hospital). The care provided to this patient was unprofessional, showed
poor judgment and was highly negligent. This patient should have been sent immediately via
emergency medical services to a hospital where he would have received an emergent CAT scan
of the head, supportive respiratory care, and aggressive therapy for his grand malignancy
93
seizures. The medical records demonstrate how this patient was poorly managed and how
quickly he deteriorated and died.
There was no adequate postmortem on this patient. The reason for death is unclear, but it is
concerning that he might have had an aneurysm that ruptured, especially given his history. The
patient pleaded for an evaluation of his aneurysms but this was not addressed by the medical
staff at Limestone Correctional Facility.
Additionally, the patient had a low T cell count. He could have had an infectious process of the
brain, especially in light of the fact that the patient had difficulty taking his medications. It is an
established pattern at the Limestone Correctional Facility that, despite indications of an ongoing
disease process, rather than evaluate the patient for a definitive diagnosis, the minimum of care is
provided until a medical crisis presents itself. And in the case of Timothy Summers, the crisis
could not be overcome and the patient died as a result.
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DEATH SUMMARY
Rickey Thompson
Rickey Thompson was a 30-year-old male with AIDS who died on 9/2/2002 at the Limestone
Correctional Facility.
Mr. Thompson apparently died suddenly after being administered magnesium citrate for
constipation and then vomited a bright red material. Unfortunately, the documentation from a
week prior to his death was not available from the chart. The only exception is a note on
9/2/2002 by Dr. Simon which lists the patient's problems. Dr. Simon also reports that the patient
had signed release of responsibility forms and a DNR. (Do Not Resuscitate)
The patient also had cirrhosis, but review of the records showed that he was hepatitis B and
hepatitis C negative. I was unable to find any further evaluation for his cirrhosis, including no
hepatitis C viral load. Many patients who are co-infected with HIV and hepatitis C can be
hepatitis C antibody negative, yet have hepatitis C virus detectable in their blood. The patient
also had depression of his bone marrow cells as well as a history of clinical depression.
On review of the patient's chart, there were multiple occasions when the patient apparently did
not go through the pill line to receive his antiretroviral therapy or his medications for prophylaxis
against opportunistic infections. He was counseled to go through the pill line, but there was no
attempt to understand why the patient was not going through the pill lines or why he was not able
to take the medications.
On 08/09/2002, the patient was seen by the physician and diagnosed with probable pneumonia.
He was written for a prescription of Levaquin. Interestingly, this medication was withheld by a
nurse claiming that the patient might have had a possible allergy. Unfortunately, the nurse did
not call the physician, but instead decided to withhold the medication permanently. The nurse’s
withholding of a prescribed medication is only with precedent for one dose; she should have
called the physician to verify her suspicions.
IMPRESSIONS:
There are clear patterns of lack of care and inadequate care at this facility.
This is another patient from the Limestone Correctional Facility who had AIDS and chronic
hepatitis and cirrhosis with no known cause. In a standard system of medical care, any patient
with cirrhosis should have an appropriate diagnosis. Any patient who is infected with hepatitis C
can show no antibodies, yet have the virus present in the blood. However, these tests were not
obtained in this patient. The patient did have very advanced cirrhosis and did die from his
disease at the Limestone Correctional Facility.
95
The patient had a history of depression. A review of the records shows his frustration with the
system. It is uncertain whether he had a good understanding of why it was important for him to
take his medications. There are many notes in the chart that document that he did not show up in
the pill lines to take his medications. However, there was no documentation of discussions with
the patient why it was important for him to take his medications. There was no recent psychiatric
or psychological assessment in his record.
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DEATH SUMMARY
Henry Turner
Henry Turner was 35-years-old and died of AIDS on 8/3/2002 at the Limestone Correctional
Facility at 4:06 p.m.
Mr. Turner carried the diagnosis of AIDS with a low T cell count of less than 20 and a viral load
of greater than 500,000. He was also diagnosed with AIDS wasting, Mycobacterium avium
complex, and bed sores. The patient was on a complicated antiretroviral regimen consisting of
Bactrim, Mycobutin, ethambutol, clarithromycin, HAART. The patient was also receiving oral
supplementation for AIDS wasting.
The patient was initially housed at Kilby Correctional Facility. On 5/15/2002, he was seen by a
nurse on intake. On 6/27/2002, the patient was found by one of the officers and noted to have
“five old trays” in his room, “three bags of old garbage, and in filthy clothes. The officer sends
for a runner.” On 6/28/2002, the patient was transferred to Limestone Correctional Facility
health care unit. While on the inpatient unit, the patient had 100% compliance with his
medications. 100% compliance would be expected because the nurses brought his medications
to him. He continued to take all of his medication every day until 8/1/2002. Two days before
his death, the physician made the decision not to treat the patient with any more medications
because she felt that it would not make any difference.
There was no team consultation or consultation with other physicians or medical ethicist before
the patient’s treatment was stopped. The patient deteriorated rapidly after his medications were
discontinued. He continued to have fevers and severe wasting.
IMPRESSIONS:
This patient was an end-stage AIDS patient who deteriorated rapidly at the Limestone
Correctional Facility. He appeared to have a severe infection which did not appear to be
responding to treatment. Unfortunately, no other possible infections were investigated in this
patient, so it is uncertain whether he died of the Mycobacterium avium complex or of some other
infection. Regardless, the patient passed away from a febrile illness.
It is noteworthy that the patient was 100% compliant to all his medications. Patients who are in
the inpatient health care unit take more of their medications because it is much easier for them to
be compliant. Non-compliance is often a function of the design of the pill line in Dorm 16.
I was unable to find any discussions regarding end-of-life care, DNR orders, or advanced
directives in this patient’s record.
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As in many of the other patients’ charts, poor care at Kilby is a common problem. This
advanced- AIDS patient had been found after three weeks of living in a dirty room without
having bathed. The condition of the room described is unacceptable.
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DEATH SUMMARY
Freddie White
Freddie White was a 51-year-old male with AIDS who died on approximately 6/9/1999. His
entire medical records have been reviewed which do not contain an autopsy or the
documentation from the last day of his life. Therefore, it is unclear to tell exactly which day he
died.
The patient had a rather extensive inpatient hospitalization when he was diagnosed with
Cryptococcal meningitis and was appropriately started on an antifungal agent. He was also
diagnosed with pancreatitis and C. difficile colitis. The patient was put on medications and had
multiple complications from these medications which required rather intensive therapy while he
was an inpatient. The discharge summary indicates that he was admitted for at least a one-month
period and possibly longer. The patient was transferred back to the Limestone Correctional
Facility on 6/3/1999.
When the patient was discharged from the hospital, his electrolytes were stable. At Limestone
Correctional Facility, the patient’s electrolytes soon became dangerously unstable. He was given
Potassium supplementation. On 6/6/1999, he had a high potassium level of 5.1 which increased
to 6.9 on 6/9/1999. He was then given medication -- Kayexelate -- to decrease his potassium
level. It appears that he also went into acute renal failure and his creatinine on 6/6/1999
increased to about 2.4, which means he lost about half of his kidney function.
The labs from 6/6/1999 indicate that he went into rapid liver failure. The patient continued to be
managed at Limestone Correctional Facility by Dr. Khouri, who documented the patient’s
condition very poorly and illegibly. On 6/8/1999, the patient had critical lab values of
bicarbonate of 7 (meaning profound metabolic acidosis), potassium of 7.3 (nearly twice the
normal level), and a creatinine of 3.3 (a loss of more than ½ of the kidney function). He had
multiple EKG’s with abnormalities.
The patient rapidly expired on 6/9/1999 of an unknown cause. There was no indication that the
patient signed any Do Not Attempt Resuscitation orders or had any Advanced Directive.
IMPRESSION:
This is a poorly documented series of medical records. This patient had a treatable illness. He
had a prolonged hospital stay and was stable on his discharge from the hospital and died within
six days of his discharge to the Limestone Correctional Facility.
It is evident that given his electrolyte fluctuations, that he was not being managed appropriately.
It is likely he died as a result of his very rapid liver and kidney failure. The records are unclear as
to why this patient was not readmitted to the Intensive Care Unit given his severity of illness
soon after his discharge.
99
Mr. White is another AIDS patient at the Limestone Correctional Facility who was poorly
managed, neglected, rapidly declined and died after a prolonged hospital stay where he had been
stabilized.
100
DEATH SUMMARY
Dewayne Wilder
Dewayne Wilder was a 37-year-old HIV positive patient who died of presumptive Pneumocystis
carinii pneumonia at the Limestone Correctional Facility on 4/17/1999.
This review will focus on the medical records immediately prior to the death of the patient.
These records are the most revealing addressing inadequate medical treatment.
On several occasions, the patient presented to the clinic at the Limestone Correctional Facility
complaining of shortness of breath. An emergency treatment record dated 3/13/1999 noted that
the patient was experiencing problems breathing. He was provided Tylenol and observed for a
short period. He was then sent back to his dorm.
Another emergency treatment record dated 3/15/1999, documented that the patient was
experiencing problems breathing. It was also noted that he had been ill for seven days with fever
and weakness. On these two occasions, his condition was listed as “satisfactory on discharge.”
This appears to be a pattern throughout his stay at Limestone.
A chest x-ray obtained on 3/17/1999 showed that the patient had worsening Pneumocystis carinii
pneumonia. The patient was seen by a physician on 3/16/1999 and diagnosed with bronchitis. He
was also diagnosed with wasting syndrome with profound weight loss. However, this diagnosis
was not evaluated further, even though there are many potential causes for wasting in HIV
infected patients.
Because the patient continued to experience severe respiratory difficulty, he was seen again on
3/29/1999 by a physician and started on treatment for Pneumocystis carinii pneumonia. The
physician started the patient on oral therapy for mild Pneumocystis carinii pneumonia, even
though he clearly had severe Pneumocystis carinii pneumonia. On 4/5/1999, the patient declined
and his oxygen saturation was noted by the physician to be 70%. This was his oxygen saturation
on 5-1/2 liters of oxygen, indicating severe respiratory distress. In fact, the physician’s
assessment reported “respiratory failure secondary to Pneumocystis carinii pneumonia.” Yet, no
further treatment was initiated. The patient was kept on his current therapy and no further
evaluation was conducted.
On 4/12/1999, the patient experienced some improvement. However, the patient continued to
have fevers. On 4/14/1999, the physician reported that the patient was “slowly resolving, but still
in respiratory distress.” Meanwhile, nursing notes in the chart documented that on 4/10/1999, the
patient stated “I am afraid to go to sleep. Please stay and talk to me and watch me.” The nurses
noted that his oxygen saturation was low at 81% on five liters and the patient was in respiratory
distress with rapid respirations.
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On 4/12/1999, the patient's oxygen saturation recorded by the nurse was 76% on 4-1/2 liters. On
4/13/1999, the patient was observed to be “weak, groggy, very dyspneic” (short of breath). He
was complaining of “great difficulty breathing.” Despite no clear reasoning, the nurses
encourage this suffocating patient to attempt to ambulate. On 4/14/1999, the nurses reported
that the patient was restless and panicky. “His anxiety is high.” Again, the nurses noted that the
“patient refuses to try to ambulate.” On 4/14/1999, the patient had a visit from his family. At
that time, he was started on prednisone which was indicated for treating worsening Pneumocystis
carinii pneumonia. Yet, it was too late.
On 4/15/1999, the patient was placed on “high oxygen” at 10 liters per minute. As expected,
given that the patient had severe Pneumocystis carinii pneumonia or some other diagnosis, that
he was on sub-optimal therapy and that he was started on prednisone too late in the course of his
disease, he expired two days later on 4/17/1999 from respiratory failure.
IMPRESSIONS:
There is a pattern addressing the care at the Limestone Correctional Facility that even the
minimal standards of acceptable care are not being followed. Numerous patients are permitted to
drown in their own respiratory secretions and suffocate while under the care of the medical and
nursing staff. It is improper that this patient had such severe respiratory difficulties and that his
condition was permitted to worsen without being treated or worked-up appropriately for some
other possible illness.
The treatment this patient received was sub-optimal and inappropriate.
In addition, the patient had a high viral load. The patient was not appropriately treated with
antiretroviral therapy. A review of his medical records demonstrates that he expressed some
complaints addressing side effects. These side effects were most likely secondary caused by the
medications not being administered with food. His side effects were secondary to taking the
medications on an empty stomach.
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DEATH SUMMARY
Iverson Williams
Iverson Williams was a 36-year-old HIV positive patient who died at the Huntsville Hospital on
11/15/2000 at 11:07 p.m.
The patient apparently died of Pneumocystis carinii pneumonia with possible secondary bacterial
pneumonia, although medical records from the Huntsville Hospital are unavailable. The patient
went into respiratory distress approximately five days prior to his death and was transferred to
the hospital. He had a very low T cell count on 11/08/2000 of 15. The patient's chart is riddled
with notes of his refusing blood draws and refusing medications throughout almost his entire
incarceration.
Most significant in this patient's medical record is the volume -- pages upon pages -- addressing
the patient's severe psychological problems. The patient spent a large amount of time in
administrative segregation for behavioral problems. There is many years of documentation that
the patient was threatening to harm himself. At one point, he even set some fires or threatened to
set some fires. Thus, as documented in the medical record describing his behavior, the patient
had severe behavioral problems.
There were also notes documenting that the patient had a depressed affect and was on suicide
watch multiple times. His depression was also evidenced by his multiple complaints and possible
somatization from his multiple health service request forms for complaints such as headaches,
dizziness, nausea and vomiting throughout the course of his incarceration.
The patient's chart is filled with disciplinary segregation -- medical type diaries -- which exist
soon up to his dying days when he was transferred to the hospital on 11/10/2000. I was unable to
find any detailed psychiatric or psychological evaluations in the medical records, although there
were some present. On 6/13/2000, there is a cursory psychological evaluation which states that
the patient has a personality disorder. There is a note in his chart on 8/19/2000, apparently from a
psychiatrist, which states that the patient was seen in the inpatient unit. In the note, it was
discussed that the patient was coherent, calm and refusing to take his medications. His diagnosis
was personality disorder and continued psychiatric evaluation.
IMPRESSION:
Mr. Iverson’s biggest problem was that he was unable to comply with his HIV medications due
to his psychological and psychiatric problems. Psychological and psychiatric issues are not my
area of specialty. However, one can review these medical records and not find any in depth
psychiatric or psychological assessment. This is appalling. The patient spent most of his entire
period of incarceration in administrative segregation, and experienced severe psychological and
psychiatric problems. It would seem appropriate that a patient with this many problems would
have had a thorough evaluation. Yet, such an evaluation was not indicated in the medical
records.
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In addition, this patient may not have been competent to make the decisions refusing his own
medical care, which he was permitted to do. His chart contains his own handwritten notes
documenting his own paranoia and delusions.
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DEATH SUMMARY
John Willis
John Willis died at the age of 35 on 03/28/2002 at the Huntsville Hospital Critical Care Unit.
The patient was a previously fairly healthy HIV positive gentleman who, at least prior to his
death had a fairly high T cell count of 373 (24%) and a moderately low viral load at 9,900. As a
result, he was appropriately not on any antiretrovirals.
The patient died of kidney failure.
In December 2000, the patient had a normal creatinine of 1.3. This was reassessed on 07/27/2001
when his creatinine had increased to 2.3. This represented a loss of approximately ½ of his
kidney function at that time. Apparently the patient was seen one month later. During that
month, there was no workup (not even a simple analysis of urine much less a biopsy) concerning
why this otherwise relatively healthy patient should have such an acute change in his kidney
function with a potential life-threatening shut-down of his kidneys.
Unfortunately, the patient was not seen again for more than four months until 12/06/2001. At
that time, it is noteworthy, his kidney failure was not even mentioned as a problem by Dr.
Simon. The patient returned to clinic almost three months later, on 02/28/2002. At that time, the
patient was found to be in total kidney failure. He had a BUN of 68, a creatinine of 7.9, and a
high potassium of 5.5.
The patient, at this point, did have an evaluation and was seen by a kidney specialist, who
recommended that the patient go on hemodialysis (artificial “kidney machine”).
The patient continued to be followed. On 03/20/2002, the patient was scheduled to have a urine
collection, which was not properly collected. By 03/25/2002, the patient's renal function had
deteriorated further as evidenced by a rising BUN and creatinine. It was assumed at that time that
the patient was oliguria (i.e., had low renal output), or was totally anuric (i.e., no renal output),
although the patient was not followed. On 03/25/2002, he was showing evidence of fluid
overload as evidenced by his swollen face. On 03/25/2002, the patient was scheduled to have a
chemistry panel and electrolytes. Patients in renal failure have disturbed electrolytes and can die
of cardiac arrhythmias.
The blood test was not picked up that day; it was not picked up, according to Dr. Simon’s
notation, until the following day, 03/26/2002. Two days later, on 03/27/2002, the BUN was
exceedingly high at 165 with a creatinine also incredibly high at 25. These laboratory values are
as high as I have previously ever seen. The patient's potassium was 6.5, approximately twice the
norm. On 3/27/02, Dr. Simon prescribed magnesium citrate, which would induce diarrhea.
Magnesium citrate was not a reasonable treatment for elevated potassium; there are more
aggressive and better measures. The patient was sent for emergency dialysis to the Huntsville
Hospital. Unfortunately, the patient died the next day on 3/18/2002.
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IMPRESSIONS:
This patient’s case highlights the problems that occur repeatedly at the Limestone Correctional
Facility. A patient with a potentially very serious illness is not thoroughly evaluated, or the
patient is not followed regularly or closely because of a lack of access to care or a lack of chronic
care clinics. As a result, the patient will present in extremis and has past the stage for any
medical treatment.
This patient had very high T cells, and no complicating illnesses. His kidney dysfunction initially
could have been evaluated and treated appropriately. In fact, his renal failure could have been
supported by hemodialysis. There was no reason that this patient could not have lived for several
years at least after this diagnosis.
Unfortunately, his kidney disease was allowed to progress to such a severe degree and so rapidly
that the patient again was admitted to the hospital. In all probability, this patient died either of
cardiac arrhythmia, or from an infection. His listed cause of death is sepsis. The major cause of
the patient's death is simply that his kidneys shut down and the patient was not supported
appropriately. The patient’s high potassium was not managed appropriately.
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DEATH SUMMARY
Earnest Wynn
Earnest Wynn was a 39-year-old male with AIDS who died at the Limestone Correctional
Facility on 02/16/2002.
The patient had advanced AIDS with a T cell count of 20. He had a history of Pneumocystis
carinii pneumonia, a history of treated tuberculosis, and a history of AIDS wasting. Wasting
was ultimately the cause of his death.
The patient’s most recent incarceration began in 06/2001. He had a fairly rapid decline
thereafter. The patient was seen regularly in the health care unit complaining of diarrhea and
vomiting. He reported an inability to take his antiretroviral medications because of nausea.
Patients at Limestone Correctional Facility do not receive their antiretroviral therapy with food.
This causes many Limestone patients to have severe nausea. Antiretroviral medication would
have been vital to this patient because his T cell count was only 20.
The patient continued to have chronic gastritis. Because he was experiencing such severe weight
loss, he was seen by Dr. Simon. She prescribed extra meals and extra bread for the patient. It
appears in the medical record that the patient did not receive this extra food. He continued to
complain of being hungry.
The patient was seen on 12/26/2001 by the physician assistant. She reported that the patient was
not able to take his medications secondary to nausea. He was then seen by Dr. Simon on
12/29/2001. This is a very disturbing note. The quote is “begging for sandwiches because he
can’t eat solid food. Burst into tears during evaluation. Emaciated looking.” At that visit, the
physician did little intervention. At that time the patient was given some intravenous fluids. He
was also given medication to decrease his diarrhea, but no medications are given to increase his
appetite or to decrease the HIV wasting syndrome. The patient continued to decline.
He was seen three days before his death on 02/13/2002, again by the physician. Again, he was
diagnosed with AIDS wasting and chronic diarrhea. No proper evaluation and intervention was
done at that time. The patient expired on 02/16/2002 of HIV wasting.
A review of the patient's medical administration records indicate that eventually he was given
anti-diarrheal agents. However, there is no notation in any of the medical records indicating that
the patient was administered any extra food or any medication for the AIDS wasting.
IMPRESSIONS:
This was a patient with advanced AIDS. Like many of the patients at the Limestone
Correctional Facility, he had extreme difficulty taking his medications because the medications
are administered without coordination with meals. He also had AIDS wasting exacerbated by the
lack of proper nutrition at the Limestone Correctional Facility. The patient was prescribed extra
food, but it did not appear to be administered. He continued to complain of needing food. At one
point, the patient was put in the inhumane position of begging the doctor for food. This patient
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was literally starving to death. In fact, the patient was feeling so poor that he burst into tears. He
appeared emaciated, yet the medical staff did nothing to try to increase the patient's critical mass
or alleviate his suffering. After reviewing dozens of volumes of medical records, I have seen a
pattern of the medical staff at Limestone doing little to help their patients’ misery and suffering.
For many years, it has been the standard of care to give patients life-saving medications to
increase their critical mass when they have severe wasting. However, none of these medications
have been prescribed at the Limestone Correctional Facility. There have been a large number of
patients who have died of AIDS wasting over the past several years. In my review of all of their
medical records, I have not witnessed one patient treated with the proper medications to treat
AIDS wasting syndrome.
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DEATH SUMMARY
Marvin Youngblood
Marvin Youngblood was a 39-year-old male with an HIV infection who died on 9/5/2000 at the
Limestone Correctional Facility.
The patient died of multiple myeloma, a cancer of the bone marrow cells. The patient develops
secondary problems from this condition. These problems include kidney failure, wasting and
decreased mental status.
On 12/22/1999, the patient presented for a laboratory draw. It was discovered that he had a
protein of 9.9 and an albumin of 3.0. This laboratory report was signed by the attending
physician, Dr. Khouri. However, no further work-up was administered. These laboratory values
were very abnormal, and the elevated protein should have had further evaluation, especially for
multiple myeloma which the patient ultimately was diagnosed with and died from 9 months later.
The patient was lost in the medical system and a follow-up was not conducted, or he received no
further evaluation for this problem. In fact, the next blood draw was not until approximately five
months later on 2/3/2000. The patient’s blood draw showed critical laboratory values with a
calcium of 14.5, among other abnormal laboratory values. 14.5 is an extremely high calcium
level that should have been addressed immediately. But the laboratory values were not co-signed
until four days later by the attending physician, Dr. Khouri. There were no immediate responses
by the medical staff to this critical laboratory value or several others until the patient was
admitted to Huntsville Hospital four days later, on 2/7/2003.
During his stay at the Huntsville Hospital, the patient was diagnosed with very advanced
multiple myeloma. Multiple myeloma is a cancer involving bone marrow tissues. He also had
severe secondary complications, which included renal failure. The Huntsville Hospital staff
appropriately documented that “after discussing the situation with the family and the patient on
at least three different occasions, the family decided to defer aggressive treatment.” Thus, the
patient was placed on Do Not Resuscitate status and Do Not Attempt Aggressive Therapy.
The patient was transferred back to the Limestone Correctional Facility where he remained in the
inpatient facility until his demise several months later. On 2/10/2000, during re-intake to the
Limestone Correctional Facility, Dr. Khouri recommended “hospice care” and then followed this
recommendation with “by fellow inmate and friend.” This recommendation demonstrates that
Dr. Khouri did not understand hospice care and that it is inappropriate for fellow inmates and
friends to provide this kind of care.
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The patient was placed in the inpatient unit at Limestone. He was placed on minimal comfort
care. Given the lack of adequate nursing at Limestone, the patient developed a severe bed sore on
his back side. Chelsea Hammac died on 9/5/2000.
IMPRESSIONS:
This patient presented with clearly abnormal laboratory values. He had a protein of 9.9 which
was above the normal level and an albumin of 3.0. These levels indicate that there was an
obvious medical problem, including multiple myeloma. The Limestone Correctional Facility
physician did not work-up these abnormal laboratory values. Instead, he waited until the patient
presented several months later, looking very ill and having advanced cancer. Once the patient
presented in extremis, his laboratory values indicated that he needed to be treated urgently.
However, the physician and medical staff did not initiate treatment. A calcium of 14.5 is very
high and will cause a patient to have decreased mental status with cardiac arrhythmias.
The patient was then sent to Huntsville Hospital. Given his advanced disease, the Huntsville
Hospital staff discussed the prognosis with the family and the patient who decided on no further
aggressive therapy. Yet, the patient was sent back to the Limestone Correctional Facility where
he was provided minimal care by the nursing staff. The care was so minimal, he developed a
severe bed sore.
Another concern is that Dr. Khouri writes in his note in the medical chart that the patient should
receive hospice care by fellow inmates and friends. Hospice care is a multidisciplinary approach
to caring for patients who have terminal illnesses. Clearly the Limestone Correctional Facility
does not have a medically acceptable hospice care program.
This case is another example of a patient whose health care was below any acceptable standard
of care. In fact, this patient was grossly neglected by the medical and nursing staff at the
Limestone Correctional Facility.
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SUMMARY
Stephen Tabet, MD, MPH
SUMMARY OF THE CARE AT LIMESTONE CORRECTIONAL FACILITY
The most egregious medical failure at Limestone is the number of preventable deaths. I
reviewed the medical records of 38 HIV-infected patients who died at Limestone since 1999. In
almost all instances the death was preceded by a failure to provide proper medical care or
treatment. Consistently, patients died of preventable illnesses. Patients with serious diseases
experienced serious delays in medical care or were not treated at all. Chronic care clinics are
unheard of at Limestone. Life-threatening laboratory results were treated routinely instead of
urgently. Other tests such as radiographs showing pneumonia were commonly not assessed until
many days later. At least one patient had such severe pneumonia that he suffocated in front of
the medical staff – despite the patient’s requests for treatment, he was not sent to a hospital until
his condition was irreversible. CPR was rarely attempted in any critically ill patient that I
reviewed.
The deaths of HIV infected inmates at Limestone are not reviewed internally. The
coroner provides only a physical description of the patients’ bodies. The medical staff’s
documentation of the events leading up to the deaths of inmates is deplorable. There are no
internal or external mortality reviews or quality improvement reviews of deaths. Without the
medical staff assessing why so many patients are dying, they cannot identify and solve the
problems within their system.
The current medical system does not appreciate the cost-effectiveness of ensuring
patients receive preventative care. For instance, assuring that a patient receives life-saving
Bactrim (one pill only three times per week) costs merely pennies per day yet prevents a deadly,
expensive-to-treat infection called Pneumocystis carinii pneumonia (PCP) – a disease that many
patients at Limestone seemed to have needlessly died from. Patients, who clearly do not
understand the consequences of not taking these life-saving antibiotics, are allowed to stop
taking them without being counseled by the medical staff. Patients in such closely observed
settings should at least receive preventive therapy. Such a simple measure as allowing the
patient to take the medication back to his unit (often called “keep on person”) is not even an
option for patients at Limestone. It is unclear why.
Patients at Limestone are treated like they are nuisances. They are forced to interrupt
their much-needed sleep at 3:00 a.m. each early morning to stand in a pill line outside, often in
cold, wet weather or sweltering heat, for up to forty-five minutes to receive their life-saving
medications. Many of these AIDS patients are too sick or unable to stand long enough to wait in
line. Thus, they can not obtain their medications, and sometimes the medications are not
available. This leads to lapses in medical care, increases the potential for resistant forms of HIV,
and results in further mistrust by the patients in the medical system.
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HIV-infected patients at Limestone Correctional Facility are totally segregated from other
inmates. This presents a serious problem in terms of medical emergencies. Limestone
administration apparently require that the prison facility be “shut down” when moving HIVinfected patients. “Shutting down” an entire prison takes a considerable amount of time; if an
HIV-infected patient has a medical emergency and needs to be transferred off the facility, the
critical time period is quickly lost and many patients have needlessly died.
Medically necessary dietary requirements for diabetics or undernourished patients are
virtually non-existent. Staff indicates that they are strongly discouraged from writing (by the
Department of Corrections) for special diets for patients, even when indicated. It must be
acknowledged that certain patients have specific dietary needs that must be adhered to. Specific
dietary requirements for diabetic patients, patients in renal failure, or under-weight patients is a
medical issue that requires attention. A large proportion of patient who died at Limestone were
severely malnourished and not receiving adequate nutrition or vitamin/mineral supplementation.
The physically handicapped and disabled suffer disproportionately. They are denied
access to baths. The only way of cleaning their bodies in Dorm 16 or Dorm 7 is by showering an often impossible task for patients who are unable to get out of their wheelchairs and step over
a high ledge to access the shower. There are numerous areas I toured in the facility where
accessibility for the handicapped is disregarded and neglected. For example, there are not
adequate railings or ramps for wheelchair access. The medical understaffing also leads to the
inappropriate use if inmates caring for disabled patients.
The open warehouse where approximately 2501 HIV-infected patients live is
overcrowded.
Side-by-side and head-to-toe bunk arrangements place these immune
compromised patients and the staff at an undue risk of acquiring contagious diseases. This is
evidenced by the recent widespread outbreak of a staphylococcal bacteria infection. I examined
many patients who had clear evidence of staphylococcal skin infections – both new infections
and scars. Reports from other facilities underscore the need for clean and separate living
facilities particularly for patients who are immune compromised and more likely to spread
diseases. I suspect the patients will continue to keep getting and spreading boils and abscesses
that spread like wild-fire given the over-crowded sleeping and living conditions at Limestone. I
have been told that Summer, 2003 has heralded additional skin infections as evidenced by
increased complaints from patients to their attorneys.
1
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NaphCare=s inmate population statistics for Limestone are as follows:
December 2002 - 309 HIV infected inmates and 57 AIDS infected inmates;
January 2003 - 307 HIV infected inmates and 55 AIDS infected inmates;
February 2003 - 310 HIV infected inmates and 54 AIDS infected inmates;
March 2003 - 288 HIV infected inmates and 52 AIDS infected inmates.
Without adequate infection control practices, the possibility of an outbreak of drugresistant tuberculosis and the subsequent deaths is acute. Some patients request to be transferred
to the lock-down units where they will at least be afforded some privacy and physical barriers to
potentially deadly infectious diseases.
Because of a broken, severely stressed or often non-existent medical system, patients are
needlessly dying and suffering from AIDS-related complications and other illnesses that could be
prevented. The conditions at Limestone Prison are unsafe for both the incarcerated and for the
staff. There is a sense of hopelessness and helplessness among the patients at Limestone -- to a
degree that I have not witnessed prior.
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INITIAL RECOMMENDATIONS
Stephen Tabet, MD, MPH
Limestone Correctional Facility has a vast array of significant medical problems. Moreover, the
standard of medical care rendered at Limestone falls far below the standards in the community or
those standards set by organized bodies described in the introduction to this report. For this
report, I will make only recommendations that I feel need to be addressed urgently. In addition
to these minimal recommendations, there are many changes that could be put into place to
develop a sound system of medical care that are not currently being addressed at Limestone. The
following recommendations address what I see to be the most serious problems at the prison
1. Deaths. The number of deaths and the manner in which HIV-infected patients are dying
at Limestone is a huge concern and present issues of potentially serious medical liability.
All deaths need to be thoroughly evaluated by a medical doctor with expertise in the area.
Full autopsies should be performed on all patients dying at Limestone until this
disturbing trend is reversed.
2. Physician and mid-level staffing. Limestone is dangerously understaffed in terms of
medical personnel according to accepted guidelines for incarcerated medical settings. Dr.
Simon has an overwhelming task to perform with only one Physician’s Assistant. One
medical doctor serving as Medical Director and providing care to over 2800 patients-including 300 with the HIV or AIDS-- is overwhelming and dangerous. At least another
full-time physician and two other mid-level practitioners (physician’s assistants or nurse
practitioners) are needed to adequately provide care for the large number of sick patients
at Limestone. Limestone staffing levels are far below what is normally accepted for
provider staffing in a facility of this size with this level of acuity in terms of patient load.
3. Inmates providing care. Because of the shortage of nurses, inmates are called upon to
provide nursing care -- especially in the inpatient unit. Inmates can provide comfort and
company to other inmates, but must not provide nursing care.
4. Nursing. Nursing is very understaffed and many nurses are poorly trained at Limestone.
Nurses need training in CPR as well as ongoing continuing education. Nurses at
Limestone have made serious errors and patients have died or suffered needlessly. The
numerous unfilled nursing positions need to be staffed. The National Commission on
Correctional Health Care (NCCHC) guidelines need to be followed in terms of adequate
nursing levels and training.
5. Infection Control. Infection control practices and guidelines are not being adhered to.
Inmates with contagious diseases should be treated and isolated from the population
especially given an HIV-infected person’s extreme vulnerability to these diseases.
Outbreaks of infections need to be investigated and treated accordingly. National
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resources such as the Centers for Disease Control and Prevention need to be called upon
for assistance when necessary. Staphylococcus bacterial infections, in particular, are a
problem and need to be eradicated as one would in any closed setting. Prevention, with
respect to infectious diseases, is severely deficient at Limestone and needs to be
integrated as a part of a patient’s medical care to decrease morbidity, mortality, and
unnecessary costs.
6. Pharmacy and Medication Supply. Multiple patients disclosed that Limestone did not
provide adequate medications because the nursing staff often ran out. Patients need to be
provided medications on a regular and consistent basis. Running out of medications is
unacceptable. The pharmacy needs to be adequately stocked and the inventory properly
managed. HIV-infected patients need to take their antiretroviral medications consistently
or they will develop drug-resistant HIV, fail medication therapy, and die. Additionally,
inmates should not provide medical care, distribute medication, or provide emergency
transport for other inmates.
7. Patients not taking essential medications. Too many patients are not taking
appropriate medications. It is unclear whether some patients comprehend the dire
consequences of not taking antiretroviral medications or preventive antibiotics. There
needs to be appropriate education and documentation that the patient understands the
consequences of not taking medications or antibiotics. Patients who are not taking simple
medication regimens such as Bactrim (one pill is taken three times per week) or Dapsone
(one small pill taken once daily) to prevent deadly Pneumocystis carinii pneumonia
should be counseled, encouraged, and supported so they can easily take these
inexpensive, life-saving medications. Opportunistic infections are deadly and very
expensive to treat. Food (a sandwich or even crackers) needs to be provided to patients
so they can take their medications without unnecessary side effects. For medications that
need to be taken on an empty stomach, then patients need to be counseled regarding this.
8. Pill Line. Making patients stand in line outside, often in the cold or extreme heat, to
receive any and all medications is counter-productive for a good therapeutic relationship.
Patients should be taken their medication on a pill cart into their dorm and/or allowed
“keep-on-person” medications when appropriate. “Keep on person” medications is a
common practice in correctional settings which allows patients to keep a few weeks or
one month of medication in their possession. They can take their medications at the
correct times and with the correct food requirements. A “keep-on-person” program
excludes any medications that are potentially dangerous and may be bartered such as
psychotropics, narcotic pain medications, and sleeping medications. Pill line at 3:00
a.m., or even 3:30 a.m., and then breakfast in the early morning is inappropriate. Patients
should be administered medications that do not interrupt their normal sleep patterns. For
example, medication could be provided at 7:30 a.m. after eating breakfast. Many of the
medications are Food and Drug Administration (FDA) approved to be taken with food, so
all patients on medications that need to be given with food must have access to food.
This will decrease the amount of side effects like nausea and vomiting, and increase
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medication compliance, as well as potentially decrease the number of illnesses.
9. Dietary requirements. Nutritional supplementation and diets are currently not
satisfying the needs of patients with illnesses that require special diets. In particular,
malnourished AIDS patients need evaluation for supplementation and mediations to
increase lead body mass. Many chronically ill patients, such as patients on dialysis and
patients with diabetes mellitus have special dietary needs. The dietary options provided at
Limestone require an assessment by a nutritionist. AIDS patients need to be given
vitamin/mineral supplementation especially given that the combination HIV therapies
toxicities.
10. Medical Emergencies. Emergency response by medical staff at Limestone is either nonexistent or dangerously slow. Patients are needlessly dying of medical emergencies. The
current rule of “locking down” the prison before providing care to a patient with a
medical emergency needs to stop. This needless delay in treatment during the first few
“golden” minutes of a medical emergency has undoubtedly hastened the death of
patients at Limestone. Patients who declare an emergency need to be either attended to
immediately by trained medical staff or transported to the infirmary for immediate
evaluation and treatment. Correctional officers should not be making medical decisions
and deciding what is a medical emergency as they are presently doing. The issues of Do
Not Resuscitate (DNR) and advanced directives needs to be consistently and
compassionately discussed with patients and the patient’s wishes need to be respected.
The current standard of the Limestone medical staff deciding for the patient how much to
do for the patient needs to cease.
11. Americans with Disabilities Act. This is an area that is so replete with deficiencies that
to adequately catalog them would require an extensive report, separate and apart from
this report. I highly recommend an extensive evaluation of these problems before a
disabled patient endures serious injury.
12. Crowded conditions and the housing unit. Patients at Limestone live in an open
warehouse with extremes in temperatures. Overcrowded conditions and the close
proximity of the beds fosters transmission of serious infections from one patient to
another. HIV-infected persons at Limestone should not be housed in such crowded,
dangerous, and inhumane conditions.
13. Monitoring. Developing an appropriate system of medical care at Limestone is going to
take time, resources and a serious commitment by the medical providers. I recommend
that health care delivery at the prison be monitored closely by an outside HIV specialist
until the program has been brought up to acceptable standards.
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Curriculum Vitae
STEPHEN R. TABET, MD, MPH
August 2003
Personal Data
Date of Birth
November 21, 1961
Birthplace
Belen, New Mexico
Citizenship
United States
Social Security Number
585-13-8908
Street Address
HIV Vaccine Trials Network (HVTN)
1100 Fairview Avenue N. J3-100
PO Box 19024
Seattle, Washington 98109-1024
Electronic Address
[email protected]
Telephone Numbers
(206) 667-2047
Facsimile (206) 667-7711
Education
1987
Biology and Business Administration (Presidential Scholar)
University of New Mexico, Albuquerque, NM
1987-91
Doctor of Medicine
University of New Mexico School of Medicine, Albuquerque, NM
1991-93
Master of Public Health, Epidemiology
University of Washington School of Public Health, Seattle, WA
Postgraduate Training
1991-1992
Intern in Internal Medicine
University of Washington School of Medicine, Seattle, WA
1992-1993
Resident in Public Health and Preventive Medicine
University of Washington School of Public Health and Community Medicine, Seattle,
WA
1993-1994
Resident in Internal Medicine
University of Washington School of Medicine, Seattle, WA
1994-1997
Senior Fellow in Infectious Diseases
Division of Allergy and Infectious Diseases, University of Washington School of
Medicine, Seattle, WA
Faculty Positions Held
1997- 1999
Acting Instructor, Division of Infectious Diseases, UW School of Medicine
1998 –present Faculty Educator, Northwest AIDS Education and Training Center
1999– present Assistant Professor of Medicine, Division of Allergy and Infectious Diseases, UW School
of Medicine
2002 – present Faculty Member, Fogarty International AIDS Research Training Program
2003 – present Senior Clinical Trials Physician - Antiretrovirals, HIV Vaccine Trials Network (HVTN)
2003 – present Affiliated Assistant Member, Fred Hutchinson Cancer Research Center (FHCRC)
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2003 – present Associate Professor of Medicine (proposed) Division of Allergy and Infectious Diseases,
UW School of Medicine
Hospital Positions
1994- 2003
Attending physician
Sexually Transmitted Disease Clinic, Harborview Medical Center, Seattle, WA
1997- 2003
Attending physician
Infectious Disease Clinic, Harborview Medical Center, Seattle, WA
1997- present Attending physician (Primary provider 1992 - 2003)
Madison (HIV/AIDS) Clinic, Harborview Medical Center, Seattle, WA
Other Positions
1995 – present Medical Director, Pacific Professional Medical Services (Supervise physician services to
Washington Department of Corrections and Department of Social and Health Services)
Honors and Awards
1991
Alpha Omega Alpha, University of New Mexico School of Medicine, Albuquerque, NM
1991
University of New Mexico School of Medicine Faculty Award for Excellence Albuquerque,
NM
1996-98
American Social Health Association (ASHA) Research Fellowship in STDs
Board Certification
1997
Diplomate, American Board of Internal Medicine
1998
Diplomate, Infectious Diseases
Medical Licensure
1991- present State of Washington, Physician and Surgeon #MD00031074
Professional Societies
American College of Physicians, Member
Infectious Disease Society of America, Member
Teaching Responsibilities and Mentoring
Daniel Corey, UW School of Medicine MS 1 – Project assessing costs associated with OI treatment and
ARV
use in Lima, Peru
Nina Kim, MD, Senior Fellow in Infectious Diseases – Issues Associated with Antiretroviral Therapy in the
Context of Phase III Vaccine Trials
Raul Salazar, MD, Almenara Hospital (Peru Social Security System) – UW AIDS Clinical Trials Unit
Regular Lecturer
Northwest AIDS Education and Training Center
Seattle Sexually Transmitted Diseases Prevention Training Center
Courses
UW Center for Health Education and Research CME
Regional Conference on HIV in the Correctional Setting
(Course Director)
CME/Invited Lectures
UW Emergency Medicine Grand Rounds
“HIV Issues of Particular Importance in the Emergency Room”
UW School of Nursing – 10th Annual Clinical Update for Nurses
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May 2003
July 2002
“Update on HIV Disease”
Country Doctor Community Health Center
“Toxicities Associated with use of Antiretrovirals”
Seattle HPTU/HVTU Community Forum
“What’s going on in the area of HIV prevention?”
University of Nevada School of Medicine – Networking for HIV Care
“Correctional Medicine: Maximal Adherence / Minimal Resistance in
the Setting of Intermittent Patient Contact”
National Conference on Correctional Health Care
“Real Life Examples: Managing Infectious Disease in Corrections”
UW Hospital Clinical Pathology Conference
Northwest AETC and Seattle STD Training Center Provider’s Update
“Care of the HIV-infected Incarcerated Patient”
“STDs in the Correctional Facility”
Pacific AETC HIV, OIs, and Hepatitis C Conference
Honolulu, Hawaii
“The Special Case of Working with Corrections”
Northwest AETC and STD Training Center Training for Washington
Corrections Center for Women, Gig Harbor
International Adult Clinical Trial Group Latin American / Caribbean
Course on HIV
(Multiple lectures)
Peruvian Conference on HIV, Pathogenesis and Treatment
“New Antiretrovirals”
“Update on Occupational Exposure to HIV, HBV, and HCV”
“Management of Treatment Failure”
“Metabolic Complications of Antiretrovirals and HIV”
Northwest AETC Montana Corrections Training Programs
Billings and Butte, Montana (Course Director)
Seattle AIDS Education and Treatment Program (STEP)
Community Forum on Antiretrovirals – Focus on QD regimens
Northwest Nevada Correctional Facility Training Program and
Preceptorship, Reno, Nevada
July 2002
September 2002
September 2002
October 2002
October 2002
October 2002
October 2002
February 2003
April 2003
May 2003
May 2003
May 2003
June 2003
August 2003
September 2003
Editorial Responsibilities
1998 – present Reviewer, Journal of Infectious Diseases
2000 – present Reviewer, Journal of the American Public Health Association
Special National/International Responsibilities
1999 – present Deputy Editor, HIV and Hepatitis Education Prison Project, Brown University, Providence,
RI
1999 – 2003
Member, US Dept. of Health and Human Services HIV/AIDS Bureau Advisory Committee
2003 – present Member, US Dept. of Health and Human Services CDC/HRSA Advisory Committee
1999 – 2003
Chair, US Dept. of Health and Human Services HIV/AIDS Bureau Treatment and Access
to Care Committee
2000 – present Member, Advisory Committee to the National Clinician’s Consultation Center, San
Francisco
2003 – present Medical Editor, HIV and Hepatitis Education Prison Project Case Study Section, Brown
University, Providence, RI
2002 – present Liaison, UW International Clinical Trials Unit – Lima, Peru Site
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2003
World Health Organization/UNAIDS consultation on modalities for access and standard of
treatment for participants with intecurrent HIV infections during vaccine, microbicide and
other prevention research trials. Geneva, Switzerland
Special Local and Regional Responsibilities
2000 – present Member, UW Sexually Transmitted Diseases Prevention Training Center Advisory
Committee
2000 – present Editor, NW AIDS Education Center Correctional Medicine Update
2001 – present Director, Northwest Correctional Medicine Education Program
Research Funding, Current
9/01/02 – 8/31/05
NIH/NIAID
Co-Investigator (10%)
AACTG International Therapeutic Clinical Trials Initiative
(P.I. Ann Collier)
Publications
1. Tabet S, Weise W. Medications obtained in Mexico by patients in southern New Mexico, Southern
Medical Journal 1990;83:271-73.
2. Tabet S, Voltura A, Wallerstein N, Koster F. Fear of AIDS: An assessment of knowledge and
attitudes of medical, nursing, and medical technology students. Teaching and Learning in Medicine
1992;4:156-61.
3. Tabet S, Palmer D, Wiese W, Voorhees R, Pathak D. Seroprevalence of HIV-1 and hepatitis B and C
in prostitutes in Albuquerque, New Mexico. American Journal of Public Health 1992; 82:1151-54.
4. Tabet S, Goldbaum G, Hooton M, Eisenach K, Cave M, Nolan C. Restriction fragment length
polymorphism analysis detecting a community based tuberculosis outbreak among persons infected
with HIV. Journal of Infectious Diseases 1994;169:189-92.
5. Tabet S, De Moya E, Holmes K, et al. Sexual behaviors and risk factors for HIV infection among men
who have sex with men in the Dominican Republic. AIDS 1996; 10:201-6.
6. Tabet S, Krone M, Hooton T, Koutsky L, Holmes K. Bacterial infections in adult patients hospitalized
with AIDS: Case-control study of prophylactic efficacy of trimethoprim-sulfamethoxazole vs.
aerosolized pentamidine. International Journal of STD and AIDS 1997;8:563-9.
7. Tabet S, Krone M, Paradise M, Corey L, Stamm W, Celum C. Incidence of HIV and sexually
transmitted diseases (STDs) in a cohort of HIV-negative men who have sex with men. AIDS
1998;12:2041-8.
8. Krone M, Tabet S, Paradise M, Wald A, Corey L, Celum C. Herpes simplex virus shedding among
HIV-negative, men who have sex with men (MSM): Site and frequency of herpes shedding. JID
1998;178:978-82.
9. Tabet S, Surawicz C, Horton S, Paradise M, Coletti A, Gross M, et al. Safety and toxicity of
Nonoxynol-9 gel as a rectal microbicide. Sex Transm Dis 1999;26:564-71.
10. Gross M, Celum C, Tabet S, Kelly C, Coletti A, Chesney M. Acceptability of a bioadhesive
nonoxynol-9 gel delivered by an applicator as a rectal microbicide. Sex Transm Dis 1999;26:572-78.
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11. Krone M, Wald A, Tabet S, Corey L, Celum C. Herpes Simplex Virus Type 2 shedding in HIVnegative men who have sex with men: Frequency, patterns, and risk factors. Clin Inf Dis
2000;30:261-7.
12. Casper C, Wald A, Pauk J, Tabet S, Corey L, Celum C. Correlates of prevalent and incident Kaposi’s
Sarcoma-associated Herpesvirus infection in men who have sex with men. J Infect Dis
2002;185:990-3.
13. Tabet S, Sanchez J, Courtois B, Lama J, Goicochea P, Campos P, et al. HIV, syphilis and
heterosexual bridging among Peruvian men who have sex with men. AIDS 2002;16:1-7.
14. Schwartz M, Tabet S, Collier A, Wallis C, Carlson L, Nguyen T, Kattar M, Coyle M. Central venous
catheter-related bacteremia due to Tsukamurella species in the immunocompromised host: A case
series and review of the literature. CID 2002;35:72-76.
15. Renzi C, Tabet S, Stucky, Eaton N, Coletti A, Surawicz C, et al. Acceptability and safety of the
Reality condom for anal sex among men who have sex with men. AIDS 2003; 17:727-31.
16. Tabet S, Callahan M, Mauck C, Gai F, Coletti A, Profy A, Moench T, Poindexter A, Frezieres R,
Walsh T, Kelly C, Richardson B, van Damme L, Celum C. Safety and acceptability of penile
application of 2 candidate topical microbicides: BufferGel and PRO 2000 Gel: 3 randomized trials in
healthy low-risk and HIV-positive men. J Acquir Immune Defic Syndr 2003; 33:476-83.
Books and Chapters
1. Tabet S, Celum C. Nongonococcal urethritis, Conn’s Current Therapy. Philadelphia: W.B. Saunders
Co., 1995.
2. Tabet S, Berg A. Screening for Cerebrovascular Disease (Chapter 4). Guide to Clinical Preventive
Services: An assessment of the effectiveness of 169 interventions. Baltimore, Maryland: Williams
and Wilkins, 1996.
3. Tabet S, Berg A. Screening for Peripheral Vascular Disease (Chapter 5), Guide to Clinical Preventive
Services: An assessment of the effectiveness of 169 interventions. Baltimore, Maryland: Williams
and Wilkins, 1996.
4. Tabet S, Root P. Continuous quality improvement in AIDS care. (USPHS publications 1999).
Electronic Publications
Tabet S. Northwest AIDS Education Training Center Correctional Medicine Update (Monthly publication
focusing on HIV, HCV, and HBV and related issues for providers working in correctional settings.)
Videos
1. Tabet S. Washington Department of Public Health and Northwest AIDS Education and Training
Center.
Taking control: Adherence and HIV/AIDS Medication. 1998.
2. Tabet S. Northwest AIDS Education and Training Center. Positive in prison: Women on
combination therapy. 1998.
3. Tabet S. Northwest AIDS Education and Training Center. Caring inside the wall: HIV
treatment in the correctional setting. 2001.
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4. Tabet S, Shuhart M. Northwest AIDS Education and Training Center. Diagnosis and treatment of HIV
and
Hepatitis C co-infected patients. 2002.
Selected Presentations/Published Abstracts
Tabet S, Voltura A, Wallerstein N, Koster F. Fear of AIDS: An assessment of knowledge and attitudes of
medical, nursing, and medical technology students. (Clinical research, Vol. 39, p. 7A); Western Regional
Meetings, Carmel, California, February 1991.
Tabet S, Palmer D, Voorhees R, Wiese W, Pathak D. Prostitution, drug use and HIV/AIDS on the streets
of Albuquerque, New Mexico, USA. Seventh International Conference on AIDS, Florence, Italy, June
1991.
Tabet S, Goldbaum G, Hooton T, Eisenach K, Cave M, Nolan C. DNA fingerprinting analysis detecting a
community-based tuberculosis outbreak among HIV-infected persons. (Abstract no. B07-1121); Ninth
International Conference on AIDS, Berlin, Germany, June 1993.
Tabet S. Tuberculosis in high risk populations. University of Washington School of Public Health Grand
Rounds, Seattle, November 1993.
Tabet S, Goldbaum G, Hooton T, Eisenach K, Cave M, Nolan C. Restriction fragment length
polymorphism analysis detecting a community-based tuberculosis outbreak among HIV-infected
persons. (Abstract no. 010); American College of Physicians Annual Session, Miami Beach, April 1994.
Tabet S, Hooton T, Koutsky L, Krone M, Holmes K. Bacterial pneumonia in adult HIV-infected patients.
American College of Physicians Annual Session, Miami Beach, April 1994.
Tabet S, Krone M, Paradise M, Stamm W, Corey L, Celum C. Herpes, the most common STD in a cohort
of high-risk HIV-negative men who have sex with men. (Abstract no. Mo.C.1634); Eleventh
International Conference on AIDS, Vancouver, July 1996.
Tabet S, Root P. The role of Continuous Quality Improvement (CQI) in federally-funded HIV/AIDS clinics.
US Department of Health and Human Services Health Resources and Services Administration AIDS
Conference, Bethesda, Maryland, April 1997.
Celum C, Tabet S, Dondero D, et al. HIV viral load in rectal mucosa and plasma: Implications for
pathogenesis studies and transmission. 35th Annual Meeting of the Infectious Diseases Society of
America, San Francisco, September 1997.
Tabet S, Krone M, Paradise M, Corey L, Stamm W, Celum C. Prevalence and incidence of HIV and
STDs in a cohort of HIV-negative men who have sex with men (MSM) (Abstract no. O-138).
International Congress of Sexually Transmitted Diseases. Seville, Spain, October 1997.
Krone M, Tabet S, Paradise M, Wald A, Corey L, Celum C. Herpes simplex virus shedding among HIVnegative, HSV-2 seropositive patients (Abstract no. O-189). International Congress of Sexually
Transmitted Diseases. Seville, Spain, October 1997.
Celum C, Tabet S, Paradise M, et al. Safety, acceptability, and biologic effects of nonoxynol-9 as a rectal
microbicide (Abstract no.O-258). International Congress of Sexually Transmitted Diseases. Seville,
Spain, October 1997.
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Lama J, Goicochea P, Chion M, Alva J, Ueda L, Cairo J, Watts D, Campos P, Sanchez J, Tabet S,
Holmes K. Comportamiento sexual y factores de riesgo para ETS e infeccion VIH entre hombres que
tienen sexo con otros hombres de Lima, Peru. XI Latin American Conference on STDs and
Panamerican Conference on AIDS, Lima, Peru, December 1997.
Tabet S, Celum C, Surawicz C, et al. Rectal sno-strips and biopsies: A simple method to assess rectal
viral load and lymphoid architecture. 12th World AIDS Conference, Geneva, June 1998.
Tabet S, Collier A, Deeks S. Post-Geneva update on antiretrovirals. Harborview Medical Center AIDS
Clinical Conference. Seattle, September 1998.
Tabet S. Adherence issues of HIV-infected incarcerated persons. Current Strategies for the
Management of HIV in Corrections. Brown University School of Medicine. New York City, October
1998.
Tabet S. Current issues in the medical management of HIV-infected patients. UCSF – Fresno Grand
Rounds. Fresno, California, October 1998.
Tabet S. Update on STD diagnoses and treatments. AIDS Healthcare Foundation, Los Angeles,
California, November 1998.
Tabet S. Antiretroviral adherence issues. Alaska Native Health Association and AIDS Education Project,
Anchorage, Alaska, January 1999.
Tabet S. A case-based approach to the advances in the treatment of HIV Disease. University of Hawaii
Grand Rounds. Honolulu, HA, October 2000.
Tabet S. Update on viral load, CD4 count, and antiretroviral resistance testing and salvage therapy. NW
AIDS Education and Training Center Training on HIV/AIDS in the African American Community.
Seattle, WA, November 2000.
Tabet S., Celum C, Dondero D, Haggitt R, Huang M, Kelly C, Brodie S. HIV-1 localization, shedding, and
CD4+ T-cell depletion in rectal mucosa. 8th Conference on Retroviruses and Opportunistic Infections.
Chicago, IL, February 2001.
Tabet S., Brodie S, Dondero D, Haggitt R, Huang M, Kelly C, Celum C. The rectal mucosa is a site of
HIV-1 replication and shedding and CD4+ T-cell depletion in men with chronic HIV-1 infection. Abstract
22. 1st International Conference on HIV Pathogenesis and Treatment. Buenos Aires, Argentina, July
2001.
Brodie S, Tabet S, Krieger J, et al. Intestinal mucosal macrophages are a principle reservoir of HIV
replication and sustain high levels of infectious virus in persons with chronic-progressive HIV infection.
Abstract 27. 9th Conference on Retroviruses and Opportunistic Infections. Seattle, WA, February 2002.
Celum C, Tabet S. Penile safety studies on PRO-2000 and BufferGel. Microbicides 2002. Antwerp,
Belgium,
May 2002.
Bartholow B, Royal S, Niedig J, Buchbinder S, Mayer K, Dyslin K, Tabet S, Goli V; The VISION Study
Team. HIV vaccine efficacy trial site characterstics associated with the enrollment of trial participants at
increased risk of HIV infection. XIV International AIDS Conference. Barcelona, Spain, July 2002.
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Bartholow B, Royal S, Niedig J, Buchbinder S, Mayer K, Dyslin K, Tabet S, Goli V; The VISION Study
Team. HIV vaccine efficacy trial site communications practices associated with enrollment of trial
participants at increased risk of HIV infection. XIV International AIDS Conference. Barcelona, Spain,
July 2002.
Ackers ML, Buchbinder S, McKirnan D, Mayer KH, Novak R, Popovic V, Heywood W, Para M, Fuchs J,
Tabet S, Vax004-Vision Study Team. Post-exposure prophylaxis among HIV-uninfected participants in
a phase III HIV vaccine efficacy trial. XIV International AIDS Conference, Barcelona, Spain, July 2002.
Bartholow B, Royal S, Niedig J, Buchbinder S, Mayer K, Dyslin K, Tabet S, Goli V; The VISION Study
Team. Enrolling high-risk HIV vaccine efficacy trial participants: Media coverage, advertising, and
opinion leader endorsement. XIV International AIDS Conference. Barcelona, Spain, July 2002.
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